American Thoracic Society Documents

An Official American Thoracic Society/European

Respiratory Society Statement: Asthma Control
and Exacerbations
Standardizing Endpoints for Clinical Asthma Trials and Clinical Practice
Helen K. Reddel, D. Robin Taylor, Eric D. Bateman, Louis-Philippe Boulet, Homer A. Boushey, William W. Busse,
Thomas B. Casale, Pascal Chanez, Paul L. Enright, Peter G. Gibson, Johan C. de Jongste, Huib A. M. Kerstjens,
Stephen C. Lazarus, Mark L. Levy, Paul M. O’Byrne, Martyn R. Partridge, Ian D. Pavord, Malcolm R. Sears,
Peter J. Sterk, Stuart W. Stoloff, Sean D. Sullivan, Stanley J. Szefler, Mike D. Thomas, and Sally E. Wenzel,
on behalf of the American Thoracic Society/European Respiratory Society Task Force on Asthma
Control and Exacerbations

THIS JOINT STATEMENT OF THE AMERICAN THORACIC SOCIETY AND EUROPEAN RESPIRATORY SOCIETY WAS APPROVED BY THE ATS BOARD
OFDIRECTORS ON MARCH 13, 2009 AND BY THE ERS EXECUTIVE COMMITTEE ON NOVEMBER 27, 2008.
CONTENTS Lung Volumes and Airway Resistance
Airway Hyperresponsiveness
Introduction
Key Points and Recommendations
Aims of the Task Force
Composite Scores for Assessment of Asthma Control
Membership of the Task Force
Categorical versus Continuous Measures of Asthma Control
Scope of the Task Force Work
Group versus Individual Data
Methodology
Time as a Factor in Composite Measures of Control
Definitions of Asthma Control and Asthma Severity
Composite Measures Expressed as Categorical Variables
Literature Review
Composite Measures Expressed as Numeric Variables
Evaluation of Outcome Measures
Summary
Development of Final Recommendations
Key Points and Recommendations
Task Force Definitions
Biomarkers of Airway Inflammation
Asthma Exacerbations
Induced Sputum
Asthma Control
Fractional Concentration of Exhaled Nitric Oxide
Asthma Severity
Exhaled Breath Condensate
Asthma Exacerbations
Serum Eosinophil Cationic Protein
Background
Key Points and Recommendations
Previous Definitions of Exacerbations
Indirect Measures of Asthma Control
Utility and Implications of Previous Definitions
Levels of Health Care
Key Points and Recommendations
Primary Care Consultations
General Concepts about Asthma Control
Unscheduled Use of Secondary Health Care
Current Clinical Control and Future Risk
Systemic Corticosteroid Usage
Validation of Measures of Asthma Control
Health Economic Data
Range of Asthma Control
Key Points and Recommendations
Time as a Factor in the Assessment of Asthma Control
Health-related Quality of Life (HRQOL)
Applicability of Control Measures to Clinical Trials
Why Measure HRQOL In Asthma?
Analysis of Asthma Control in Clinical Trials
Interpretation of HRQOL Results
Diary Data in the Assessment of Asthma Control
Choice of HRQOL Questionnaires
Methods of Recording Diary Data
Generic HRQOL Questionnaires
Diary Questions
Specific Asthma-related QOL Questionnaires
Ambulatory Lung Function
Role of HRQOL Assessment in Drug Evaluation Process
Peak Expiratory Flow Variability
Key Points and Recommendations
Analysis of Diary Variables
Summary and Overall Recommendations
Clinical Associations
Rationale and List of Measures
Key Points and Recommendations
Choice of Endpoints
Lung Function and Airway Hyperresponsiveness
Future Directions
Spirometry
Peak Expiratory Flow
Background: The assessment of asthma control is pivotal to the
This document has an online supplement, which is accessible from this issue’s evaluation of treatment response in individuals and in clinical trials.
table of contents at www.atsjournals.org Previously, asthma control, severity, and exacerbations were de-
fined and assessed in many different ways.
Am J Respir Crit Care Med Vol 180. pp 59–99, 2009
DOI: 10.1164/rccm.200801-060ST Purpose: The Task Force was established to provide recommenda-
Internet address: www.atsjournals.org tions about standardization of outcomes relating to asthma control,
60 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
severity, and exacerbations in clinical trials and clinical practice, for
adults and children aged 6 years or older.
Methods: A narrative literature review was conducted to evaluate the
measurement properties and strengths/weaknesses of outcome meas-
ures relevant to asthma control and exacerbations. The review focused
on diary variables, physiologic measurements, composite scores,
biomarkers, quality of life questionnaires, and indirect measures.
Results: The Task Force developed new definitions for asthma control,
severity, and exacerbations, based on current treatment principles and
clinical and research relevance. In view of current knowledge about the
multiple domains of asthma and asthma control, no single outcome
measure can adequately assess asthma control. Its assessment in
clinical trials and in clinical practice should include components
relevant to both of the goals of asthma treatment, namely achieve-
ment of best possible clinical control and reduction of future risk of
adverse outcomes. Recommendations are provided for the assessment
of asthma control in clinical trials and clinical practice, both at baseline
and in the assessment of treatment response.
Conclusions: The Task Force recommendations provide a basis for
a multicomponent assessment of asthma by clinicians, researchers,
and other relevant groups in the design, conduct, and evaluation of
clinical trials, and in clinical practice.
Keywords: asthma control; asthma exacerbations; asthma severity;
clinical trials; outcome assessment (health care); predictive value of tests
INTRODUCTION
Asthma is a heterogeneous condition. Its natural history
includes acute episodic deterioration (exacerbations) against
a background of chronic persistent inflammation and/or struc-
tural changes that may be associated with persistent symptoms
and reduced lung function. Trigger factor exposure combines
with the underlying phenotype, the degree of hyperresponsive-
ness and of airflow obstruction, and the severity of airway
inflammation to cause wide variability in the manifestations
of asthma in individual patients. The challenge to clinicians
and researchers is to quantify such profiles both individually
and collectively in such a way as to make the assessment of
interventions or comparisons between different populations
meaningful.
Since the early days of practice guidelines for asthma (1, 2), the
aim of treatment has been to minimize symptoms, optimize lung
function, and prevent exacerbations. While referring to this aim,
lung function was frequently the primary endpoint. With later
recognition of the importance of the patient perspective, and of
the poor correlation between lung function and inflammation and
symptoms (3, 4), clinical trials and clinical practice have in-
creasingly focused on the assessment of ‘‘asthma control.’’ This
is a summary term that implies a global assessment of symptoms,
reliever use, lung function, and the frequency/severity of exacer-
bations. To date, there has been no clear definition of asthma
control, and the criteria used in its assessment have varied widely
from study to study. This substantially limits the extent to which
clinical trial data can be pooled for meta-analysis. The definition
of ‘‘exacerbation’’ has also varied within guidelines and between
studies. The term is variously used to refer to episodes or events
occurring multiple times a week (5), or to severe events requiring
hospitalization. ‘‘Asthma severity’’ has also been used to describe
either a patient’s overall clinical status, or the intensity of asthma
symptoms or exacerbations (6).
The present Task Force was established in response to
a symposium at the European Respiratory Society (ERS) Con-
gress in Vienna in September 2003. It was approved initially by
the ERS and later extended to include the American Thoracic
Society (ATS), the aim being to provide recommendations about
the assessment of asthma in clinical trials and clinical practice.
2009
Aims of the Task Force
The primary aim of the Task Force was:
To provide consensus recommendations on standardized
definitions and data collection methods for assessing
asthma control, asthma severity, and asthma exacerba-
tions in future clinical trials.
The secondary aims were:
1. To provide consensus recommendations on standardized
measures of asthma control and exacerbations that can be
obtained retrospectively from existing clinical trial data,
to maximize the potential for pooling of data, and making
comparisons between clinical trials.
2. To provide consensus recommendations on the assess-
ment of asthma control, asthma severity, and asthma
exacerbations in clinical practice.
Membership of the Task Force
The Task Force membership was intended to represent a broad
spectrum of clinical expertise and clinical trial experience. The
Food and Drug Administration (FDA) and European Medi-
cines Evaluation Authority (EMEA) each provided an observer
to the Task Force. Written submissions were invited from major
respiratory pharmaceutical companies; three submissions were
received and circulated to the Task Force members for their
information. Employees of pharmaceutical companies and re-
presentatives of other companies with a commercial interest in
the output of the Task Force were excluded from membership
or observer status.
Seven Working Groups of three to five members provided
detailed reports about: exacerbations, diary data, physiologic
measures, composite scores, biomarkers, indirect measures, and
quality-of-life questionnaires. The Working Group reports
and the combined report were circulated to all Task Force
members for comment and agreement. Pediatric and Primary
Care Working Groups provided specialized perspective on
the recommendations from each Working Group (see WORKING
GROUP MEMBERSHIP).
Scope of the Task Force Work
The Task Force considered outcome variables from the per-
spective of their relevance to clinical trials, including those
conducted in primary care, and to clinical practice at all levels
from primary care to tertiary care. The focus was primarily on
issues relating to the assessment of asthma in those aged 6 years
and over, as the needs for children younger than 6 years were
considered to be beyond the scope of the present initiative.
METHODOLOGY
Definitions of Asthma Control and Asthma Severity
During preparation of the Task Force proposal in 2004, it was
already obvious that there were no consistently accepted
definitions for asthma control, severity, or exacerbations. This
was subsequently confirmed by literature reviews performed by
individual Working Groups (described below). Criteria based
on American, British, and international (GINA) guidelines
were cited in some clinical trial reports as measures of treat-
ment effect on ‘‘asthma control,’’ and in others as relating to
‘‘asthma severity.’’ The Task Force therefore set about estab-
lishing new definitions for asthma control and asthma severity,
based on consensus and clinical relevance. After initial round-
American Thoracic Society Documents
table discussions, Task Force members were asked to write their
own current definitions for asthma control, asthma severity, and
exacerbations. Definitions from current international asthma
guidelines were also circulated and discussed. These individual
definitions were examined for themes, using N4 Software
(Qualitative Solutions and Research Pty Ltd, Melbourne,
Australia), and were used as the basis for the construction of
ad hoc ‘‘working definitions,’’ which were again circulated,
discussed, and refined until there was agreement by Task Force
members about the concepts and the wording of the definitions.
The primary focus of this process was to develop definitions that
would have maximal clinical and research utility. These defi-
nitions were used in the subsequent work of the Task Force.
Literature Review
The Task Force members agreed that the output from the Task
Force would be a narrative review, identifying and describing
measures that were appropriate to the newly established
definitions of asthma control and exacerbations. It was not
appropriate in most cases to grade the quality of studies, as is
usually a priority for reviews about clinical efficacy (7).
The Cochrane Register of Randomized Controlled Trials
was searched for all studies published between 1998 and 2004
that contained the words ‘‘asthma control,’’ ‘‘asthma severity,’’
or ‘‘asthma exacerbation(s).’’ This yielded 440 references, de-
creasing to 356 after exclusion of non–English-language refer-
ences and those published only as abstracts, and to 327 after
exclusion of duplicates. Papers reporting studies based only
within a laboratory, emergency room (ER), or hospital were
also excluded. Thereafter, each paper was allocated to an
individual Task Force member to identify the outcome variables
that had been used to describe and/or quantify asthma control,
severity, and/or exacerbations. This search provided a subset of
clinical trial reports that had used outcome variables relevant to
previous definitions of asthma control, severity, or exacerba-
tions.
Evaluation of Outcome Measures
Papers identified by the above process were allocated to the
relevant Working Group(s) for joint assessment of the measure-
ment properties, analysis and reporting of the outcome variables,
and the information that they provided about treatment re-
sponse. The Working Groups then performed descriptive reviews
of each identified outcome variable, based on a customized
template (see the online supplement). The focus was on the
measurement properties of each variable, and its strengths and
weaknesses in the assessment of asthma control or exacerbations
(as defined by the Task Force). Task Force members were asked
to refer where possible to published guidelines or recommenda-
tions about methodology relevant to their Working Group, and
to identify additional papers that evaluated measurement prop-
erties or clinical associations for the nominated outcome varia-
bles from further literature searches. References were updated
before the final submission of this document.
Development of Final Recommendations
Finally, after considering the available outcome measures, the
Task Force developed overall recommendations for the assess-
ment of asthma control and exacerbations in clinical trials and
clinical practice. The recommendations are based on a balance
between:
1. The extent to which each measure provides information
that is congruous with the definitions of asthma and of
asthma control.
61
2. The extent to which each measure is reflective of the dual
goals of asthma treatment (6, 8, 9), namely:
(a) to achieve good control of the current clinical mani-
festations of asthma, and
(b) to reduce risk to the patient (i.e., the risk of adverse
outcomes such as exacerbations, poor control, accel-
erated decline in lung function, and side-effects of
treatment). Some of these future risks may result from
lack of control of the underlying disease process.
3. Characteristics of the outcome measures such as repro-
ducibility, responsiveness, and construct validity (associ-
ation with other measures), all of which will obviously
vary to some extent between individual outcome variables
within each class.
4. Feasibility of using the outcome measure (including
safety, accessibility, and cost).
For each of the main groups of outcome measures, key points
and recommendations for clinical trials are presented in sum-
mary boxes at the end of the relevant sections below, together
with recommendations for clinical practice, pediatric issues, and
important research questions. The overall recommendations for
assessment of asthma control and exacerbations in clinical trials,
and the rationale for each recommendation, are presented at the
end of this document (see Tables 1 and 2 in SUMMARY AND
OVERALL RECOMMENDATIONS). The Task Force recommenda-
tions for the assessment of asthma severity were previously
published (6), and are summarized below (see ASTHMA SEVERITY).
TASK FORCE DEFINITIONS
A summary of the Task Force definitions of asthma control,
severity, and exacerbations is provided below. The rationale for
the development of these definitions has been published in the
European Respiratory Journal in 2008 (6), and it is important
that the present recommendations should be read in conjunc-
tion with that paper.
Asthma Exacerbations
In clinical practice, exacerbations are identified as events
characterized by a change from the patient’s previous status.
This concept should also be applied in clinical trials.
1. Severe asthma exacerbations are defined as events that
require urgent action on the part of the patient and
physician to prevent a serious outcome, such as hospital-
ization or death from asthma.
2. Moderate asthma exacerbations are defined as events that
are troublesome to the patient, and that prompt a need
for a change in treatment, but that are not severe. These
events are clinically identified by being outside the
patient’s usual range of day-to-day asthma variation.
Although several studies have reported ‘‘mild’’ exacerbations,
the Task Force considered that these episodes were only just
outside the normal range of variation for the individual patient
and that with present methods of analysis, they could not be
distinguished from transient loss of asthma control. Hence, no
definition of a ‘‘mild’’ exacerbation can be offered (see ASTHMA
EXACERBATIONS for more detail).
Asthma Control
Asthma control is defined as the extent to which the various
manifestations of asthma have been reduced or removed by
treatment. This includes two components:
62 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
1. The level of clinical asthma control, which is gauged from
features such as symptoms and the extent to which the
patient can carry out activities of daily living and achieve
optimum quality of life, and
2. The risk of future adverse events including loss of con-
trol, exacerbations, accelerated decline in lung function,
and side-effects of treatment. More detail about asthma
control is provided in GENERAL CONCEPTS ABOUT ASTHMA
CONTROL.
Asthma Severity
Asthma severity is defined as the difficulty in controlling
asthma with treatment. After exclusion of modifiable factors
such as poor adherence, smoking, and comorbidities (10),
severity largely reflects the required level of treatment and
the activity of the underlying disease state during treatment,
which may vary depending on the underlying phenotype,
environmental factors, and comorbidities (6). There is clinical
utility in distinguishing patients with ‘‘difficult-to-treat’’ or
severe asthma from those who have ‘‘easy-to-treat’’ or mild
asthma.
This represents a change from previously published defini-
tions of asthma severity (8, 9), which was previously defined in
terms of the activity of the underlying disease process as
represented by clinical features before commencement of
treatment. The Task Force considered that current clinical
and research usage of ‘‘severe asthma’’ and ‘‘mild asthma’’
overwhelmingly focused on the intensity of treatment required.
In addition, there was insufficient research evidence that
a patient’s clinical characteristics when untreated could consis-
tently inform future management decisions, or could predict the
ease or difficulty of obtaining good asthma control once
treatment was commenced, to warrant retaining the previous
‘‘off-treatment’’ definition of severity. Further explanation is
provided in the separate publication (6).
ASTHMA EXACERBATIONS
Background
Prevention of asthma exacerbations has been identified in all
asthma treatment guidelines (e.g., References 8, 9, 11) as an
important component of establishing ideal asthma control. It
could be argued that exacerbations are the most important
outcome, because they constitute the greatest risk to patients,
are a cause of anxiety to patients and their families, result in the
greatest stress on health care providers, and generate the
greatest cost to the health care system (12). Somewhat surpris-
ingly, only in the past 10 years have exacerbations been used as
a primary outcome variable in research into the efficacy of drug
treatment in asthma (13).
Exacerbations are recognized as a common clinical mani-
festation in patients with severe asthma, and are known to
increase the risk of asthma mortality (14). However, even in
patients thought to have mild asthma, the rates of severe
asthma exacerbations have been much higher than expected
(15, 16).
In clinical practice, exacerbations are recognized as epi-
sodes that are troublesome to patients, and that prompt a need
for a change in treatment. These episodes vary considerably
in speed of onset, from minutes or hours (17, 18) to 2 weeks
(19), and in time to resolution (5–141 d [19]); they also vary in
their absolute severity, both between and within individual
patients. Clinical characteristics that cause acute distress and
impairment in one patient may represent another patient’s
2009
usual status. These events are therefore clinically identified by
being outside the patient’s own usual range of day-to-day
variation.
Previous Definitions of Exacerbations
Various terms are used to refer to exacerbations, and this
impacts on the yield of literature searches. For example, ER
studies often refer to ‘‘acute severe asthma’’ rather than
‘‘exacerbations.’’ Likewise, in ER studies, ‘‘mild acute asthma’’
may refer to episodes with FEV1 . 30% predicted (20), events
that would be regarded as extremely severe in a community-
based setting. Some studies refer to ‘‘treatment failure’’ (21), or
use ‘‘asthma attack’’ to differentiate a severe exacerbation from
an ‘‘exacerbation day’’ (22–24).
Severe exacerbations. In the reviewed literature, the defini-
tions of severe exacerbations most frequently included the
need for the administration of systemic corticosteroids (tab-
lets, suspension, or injections) (13, 16, 25, 26) at the physician’s
discretion (27–29), and/or in response to a specified decrease
in peak expiratory flow (PEF) (13, 16, 30). Other criteria
variously included emergency room visits and/or hospitaliza-
tions (13, 16) or unscheduled doctor visits (30). Some studies
excluded use of systemic corticosteroids for less than 3 days
(31, 32). Few studies reported whether closely consecutive
courses of systemic corticosteroids were handled as one or two
exacerbations.
Many definitions included a decline in PEF of 20 to 30% (13,
16, 25, 26, 33). Usually, the criterion was a change from baseline
PEF, rather than change from on-treatment PEF. Most studies
required at least 2 consecutive days of lower PEF, but occa-
sionally a single day with low PEF was accepted (26). In two
studies (13, 33) in which severe exacerbations were identified
retrospectively from systemic corticosteroid use and/or changes
in PEF, the majority were identified by corticosteroid use.
Finally, some studies included criteria for increased asthma
symptoms (30, 34) or increased rescue short-acting b2-agonist
(SABA) plus a fall in PEF (26).
Moderate exacerbations. Moderate exacerbations may be
considered to be events that require additional treatment to
prevent progression to severe exacerbation. Few studies for-
mally defined moderate exacerbations. One study defined
moderate exacerbations by use of corticosteroid tablets, and
severe exacerbations by in-patient care or ER visits (35).
Another defined moderate exacerbations by ‘‘extra controller
therapy’’ (oral corticosteroids/inhaled corticosteroids [ICS]/
long-acting b2-agonist [LABA]/theophylline) (28). In studies
that examined whether doubling (36, 37) or even greater
increases (38) in ICS dose for worsening asthma reduced the
chance of progression to severe exacerbation, the index events
obviously had to be defined by clinical criteria rather than by
the medication change itself. In these studies, the use of more
stringent clinical criteria (36) did not increase the probability of
progression to severe exacerbation (defined by need for oral
corticosteroids).
Mild exacerbations. In the reviewed studies, a range of
criteria were used to define mild exacerbations—for example,
a 15% decrease in morning PEF (26), a 20% decline in clinic
FEV1 (28), and/or an increase in reliever medication use (25, 39,
40). Some studies defined ‘‘exacerbation days’’ either singly (23,
36, 41) or as consecutive days (13), but similar features were
used in other studies to identify ‘‘poor control days’’ (16).
Vaquerizo and colleagues observed that even subtle differences
in criteria for exacerbation days resulted in large differences in
the apparent incidence of these events, and could reduce the
apparent efficacy of an intervention (23).
American Thoracic Society Documents
Exacerbations of unspecified severity. Many other studies
reported exacerbations without classifying them as to severity,
using criteria similar to those described above for severe
exacerbations (e.g., References 37, 42, and 43). Some studies
used composite criteria of symptoms, b2-agonist use, PEF, or
FEV1, or an increase in maintenance therapy (e.g., References
41, 44, and 45), but did not report the proportion of exacer-
bations identified by each criterion. Some studies required only
a single criterion to be identified (e.g., Reference 44), while
others needed two or more (e.g., Reference 46).
Utility and Implications of Previous Definitions
Severe exacerbations. Of those evaluated, almost no two stud-
ies had the same definition of a severe asthma exacerbation.
Most included the need for systemic corticosteroids (or an
increase in dose of maintenance oral corticosteroids) and/or
hospitalization/ER visit. These criteria appear to be clinically
relevant and intuitively valid. However, they are open to the
criticism that, as the reasons for the decision to begin cortico-
steroids or visit the ER are not defined a priori, the events will
differ from study to study, patient to patient, and country
to country. In a primary care study from The Netherlands,
exacerbations defined by oral corticosteroid use had low
sensitivity for doctor-diagnosed exacerbations in primary care
(47). It should be recognized that both systemic corticosteroid
use (initiated by patient or clinician) and ER/hospitalization
require a subjective assessment by the patient and/or clinician
that the event is severe enough to warrant such action. These
definitions are therefore dependent on adequate perception of
airway obstruction by the patient. However, at a group level in
clinical trials, use of systemic corticosteroids and/or urgent
health care utilization have been found to be responsive to
treatment (e.g., Reference 33), and they are relatively simple
to record.
The Task Force recommends that the definition of severe
exacerbations should include at least 3 days’ use of systemic
corticosteroids, to avoid including inadvertent or inappropriate
patient-initiated use. If systemic corticosteroids are used for less
than 3 days, the reason for discontinuation (e.g., side effects),
should be recorded. While this 3-day criterion has never been
critically evaluated and is likely to suffer from lack of precision,
it is clinically relevant, as a shorter duration of treatment is not
recommended by guidelines. For closely consecutive courses of
corticosteroids, some studies count two courses separated by at
least 1 week as separate severe exacerbations; this lacks firm
evidence, but there are advantages in a standardized approach.
The definition of severe exacerbation in terms of systemic
corticosteroid use or hospitalization is suited only to retrospective
use—for example, in the assessment of clinical trial outcomes.
It does not provide clinical guidance for diagnosis and manage-
ment of exacerbations during a clinical trial or in clinical practice.
In several studies, a poor association has been observed
between PEF criteria and clinician prescription of corticoste-
roids. This calls into question the clinical relevance of PEF in
defining severe exacerbations. In some studies, many episodes
with 30% fall in PEF were identified retrospectively from
diaries, without the patients having presented for medical care
(13, 33). This may have been due to lack of symptoms or
a reluctance to take systemic corticosteroids (as reported in
Reference 48); or the relevant paper diary data may have been
completed retrospectively (49). By contrast, in other studies (30,
50), a 30% decline in PEF was found to be too stringent
a criterion, with the majority of patients initiating extra
treatment before this level had been reached. The disparity
between the above observations may be explained by differ-
ences in baseline PEF variability between patients (51) or to
63
other monitoring-related factors. However, at a group level,
exacerbations defined by a greater than 30% decline from
baseline for 2 consecutive days are responsive to long-term
treatment (13, 33). Data from paper PEF diaries should be
interpreted with caution in the analysis of exacerbations,
because of the high proportion of retrospectively completed
entries (49) (see DIARY DATA IN THE ASSESSMENT OF ASTHMA
CONTROL). Further work on diagnostic criteria for exacerbations
is needed based on electronically recorded data.
Although increased symptoms and b2-agonist use are char-
acteristic of severe exacerbations, it is difficult to establish
appropriate criteria for general use, given the range of symp-
toms and medication use before the exacerbation. Nocturnal
symptoms appear to develop late in the course of an exacerba-
tion (30), and therefore may be an insensitive criterion to use
for the definition of severe exacerbation. In selecting criteria to
prospectively define severe exacerbations, one must balance
specificity against safety. Changes that occur for only 1 day may
potentially reflect transient loss of asthma control, rather than
an exacerbation, but for a patient who is rapidly deteriorating at
the beginning of a severe exacerbation, a 2-day wait to initiate
additional treatment may be too long.
Moderate and mild exacerbations. The concept of a moderate
exacerbation has clinical utility, as clinical practice guidelines
advise that exacerbations should be recognized and treated
before they become severe. Despite the lack of validated
criteria, it appears reasonable for a definition of moderate
asthma exacerbations to include deterioration in symptoms
and/or lung function with increased rescue bronchodilator use
that lasts 2 days or more, but that is not severe enough to
warrant corticosteroid tablet use and/or a hospital visit. How-
ever, the way in which such deterioration can be standardized
for either prospective or retrospective use in clinical trials has
not yet been established.
Defining mild exacerbations is difficult, because by definition
these episodes will be only just outside the patient’s normal
range of variation. Defining the end of an exacerbation, particu-
larly if it represents only poor control, is even more challenging.
Analysis and reporting of exacerbation data. Some studies
have analyzed the percentage of patients with at least one
exacerbation (e.g., Reference 44) or the time to first severe
exacerbation (e.g., Reference 16). The latter has the advantage,
particularly in placebo-controlled trials, that it is less likely to be
contaminated by the introduction of additional therapies, or
affected by patients with multiple exacerbations. However,
most commonly, studies have used the annualized rate of
exacerbations (13, 16, 46, 52), which has been useful in com-
paring patient populations in different studies. The statistical
issues involved in analysis of exacerbation rates have been
described in detail for chronic obstructive pulmonary disease
(COPD) (53, 54), and are also applicable in asthma. The
weighted mean (total number of exacerbations for the study
group, divided by the total duration of person follow-up for the
group) provides the best statistical estimate of the exacerbation
rate, as it is unbiased by the effect of exacerbations occurring in
a small time interval (53).
Exacerbation rates and proportion of subjects with at least
one exacerbation have been most commonly displayed by
column graphs (e.g., Reference 52). Time to first exacerbation
is often displayed by Kaplan-Meier survival graphs (e.g.,
References 16 and 55), with separate graphs used for time to
second or third exacerbation. More recently, composite graphs
have been used to display individual exacerbations for each
study subject, thus showing the time to occurrence and duration
of both initial and repeat exacerbations within the one graph
(e.g., References 56 and 57).
64 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
KEY POINTS AND RECOMMENDATIONS:
CLINICAL TRIALS
Severe Asthma Exacerbations
1. Severe asthma exacerbations are events that require
urgent action on the part of the patient and physician to
prevent a serious outcome, such as hospitalization or
death from asthma. The occurrence of severe asthma
exacerbations should be used as a marker of poor
asthma control.
2. The definition of a severe asthma exacerbation for
clinical trials should include at least one of the
following:
(a) Use of systemic corticosteroids (tablets, suspen-
sion, or injection), or an increase from a stable
maintenance dose, for at least 3 days. For consis-
tency, courses of corticosteroids separated by 1
week or more should be treated as separate severe
exacerbations.
(b) A hospitalization or ER visit because of asthma,
requiring systemic corticosteroids.
3. If severe exacerbations are defined by any of multiple
criteria, investigators should be asked to record the
specific criterion (or criteria) which were satisfied for
each episode, so that they can be better characterized.
4. The inclusion of a percentage change in PEF from
baseline is not currently recommended as a criterion
for severe exacerbations.
5. There are currently no validated criteria for the
magnitude of change in symptoms and/or b2-agonist
use that define a severe asthma exacerbation. If
included in a study, changes in PEF, symptoms, and/or
b2-agonist use should persist for 2 or more days
(unless very severe) to qualify as a severe exacerba-
tion.
Moderate Asthma Exacerbations
1. A moderate asthma exacerbation is an event that,
when recognized, should result in a temporary change
in treatment, in an effort to prevent the exacerbation
from becoming severe.
2. The definition of a moderate asthma exacerbation
should include one or more of the following: deteriora-
tion in symptoms, deterioration in lung function, and
increased rescue bronchodilator use. These features
should last for 2 days or more, but not be severe enough
to warrant systemic corticosteroid use and/or hospitali-
zation. ER visits for asthma (e.g., for routine sick care),
not requiring systemic corticosteroids, may be classified
as moderate exacerbations.
3. The magnitude of change in these outcomes will differ
depending on the population studied and each in-
dividual patient’s baseline variation.
Mild Asthma Exacerbations
A definition of a mild asthma exacerbation is not justifiable
with present methods of analysis, because the symptoms or
changes in flow rates during these episodes will be only just
outside the normal range of variation for the individual
2009
patient and may reflect transient loss of asthma control
rather than the early stages of a severe exacerbation.
Analysis of Exacerbations
Analysis of time to first exacerbation minimizes the effect of
differential drop-out and of individual subjects with multi-
ple exacerbations. Analysis of the rate of exacerbations
(reported as, for example, number/patient/year) is the most
useful for comparing between patient populations. To avoid
bias by early withdrawal, this approach should estimate the
weighted mean rate by pooling all of the exacerbations in
a treatment group of a trial and dividing by the total follow-
up time in the group.
Exacerbations in Clinical Trials in Primary Care
1. The above descriptions of moderate and severe
asthma exacerbations are applicable to clinical trials
in primary care, where exacerbations are also an
important outcome; however, the identification of
moderate exacerbations is likely to be based on
clinical rather than lung function parameters.
2. To capture exacerbations in study participants who
have a self-management plan, the structure of the plan
should be standardized for all subjects, and partici-
pants should be asked to briefly record the clinical
context of, for example, initiation of systemic cortico-
steroids, to provide confirmation that the usage was
clinically justified.
EXACERBATIONS IN CLINICAL PRACTICE
1. Exacerbation frequency should be evaluated as part of
routine asthma assessment, and so a definition for exac-
erbations is needed for clinical practice.
2. There is an urgent need for prospective rather than
retrospective definitions of exacerbations for clinical prac-
tice, to provide guidance for health care professionals and
patients in treating exacerbations.
3. Defining exacerbations on the basis of systemic cortico-
steroid use has low sensitivity for doctor-diagnosed exac-
erbations in primary care.
4. Prospective definitions that may be suitable for clinical
trials are not necessarily suitable for clinical practice,
because of differences in health care resources (e.g., 24-h
access to investigators in clinical trials), and patient and
clinician expectations about, and experience with, moni-
toring of symptoms or PEF.
5. In the clinical setting, the absolute severity of exacerba-
tions will vary considerably from patient to patient, or
over time. Therefore, asthma exacerbations should be
clinically identified by changes in symptoms and/or rescue
use and/or lung function, which are outside the patient’s
usual range of day-to-day asthma variation, and, for
retrospective analysis, are associated with an increase
from a stable maintenance dose of treatment taken by
the patient for 3 days or more.
6. For individual patients, information about the onset and
course of exacerbations should subsequently be used to
refine and customize the ‘‘trigger points’’ or ‘‘action
points’’ for the patient’s asthma action plan.
American Thoracic Society Documents
PEDIATRIC ISSUES
1. In young children with asthma, exacerbations are fre-
quent, with significant morbidity, possibly because of the
frequency of viral infections.
2. There are no reliable methods for early detection, but the
development of upper airway symptoms of viral infection
may be a useful alert.
3. The severity of exacerbations is also difficult to charac-
terize in children, because of dependence on parental
reporting of symptoms and the difficulty of measuring
lung function.
4. Many exacerbations in children are treated with increased
doses of ICS rather than systemic corticosteroids; how-
ever, until specific studies are available, these should be
considered moderate exacerbations, while the use of
systemic corticosteroids would constitute a severe exac-
erbation.
RESEARCH QUESTIONS
1. More work is needed to establish clinical criteria for
changes in symptoms, b2-agonist use, and lung function
that can be used prospectively to identify exacerbations.
This analysis should be based on electronically recorded
data, and should take into account each patient’s usual
range of variation (e.g., in symptoms or PEF).
2. The factors (clinical, psychological, and contextual) that
contribute to patient and clinician decisions to use
systemic corticosteroids or that prompt urgent health care
utilization need to be further investigated.
3. More work is needed to develop clinical criteria for pediat-
ric asthma exacerbations that can be applied prospectively.
4. More work is needed to develop simple feasible criteria
for defining exacerbations in clinical practice.
GENERAL CONCEPTS ABOUT ASTHMA CONTROL
The current definition of asthma (5, 8) comprises four domains:
symptoms, variable airway obstruction, airway hyperresponsive-
ness (AHR), and airway inflammation. No one domain is
essential to the diagnosis, and not all investigators have access
to objective testing of all four domains. In primary care, the
diagnosis of asthma is often made only on the basis of
symptoms, but, given their lack of specificity, this approach
may lead to incorrect diagnosis. Confirmation of the diagnosis
of asthma once regular treatment has been commenced is even
more difficult. There is increasing awareness in the literature
and in clinical practice of the importance of different asthma
phenotypes and their differences in responsiveness to treatment
(58, 59). Hence, the recommendations of the Task Force about
the assessment of asthma control are governed not only by the
performance characteristics of the outcome variables them-
selves (as described in the remainder of this document), but
also by the definition of asthma, the concept of differing asthma
phenotypes, and the goals of asthma treatment.
Current Clinical Control and Future Risk
Asthma control is defined as the extent to which the various
manifestations of asthma are reduced or removed by treatment.
Although severe exacerbations are more common with poorly
controlled asthma (52), they also occur in patients with other-
65
wise mild (27) or well-controlled asthma (60). In addition, some
medications, such as LABA (given alone), may control symp-
toms and lung function in the short term without reducing
inflammation or AHR (41, 61). Hence, there is increasing
recognition in asthma guidelines (9) of the need for the concept
of asthma control to encompass not only the patient’s recent
clinical state (symptoms, night waking, reliever use, and lung
function), but also to consider their ‘‘future risk’’—that is, their
potential for experiencing adverse outcomes, such as loss of
control in the near or distant future, exacerbations, accelerated
decline in lung function, or treatment-related side effects.
While current poor control predicts future poor control and
health care utilization (62), there is increasing awareness that
other pathologic and physiologic measures, independent of the
level of current clinical control, predict future risk. For example,
exhaled nitric oxide has been used as a ‘‘predictor’’ of loss of
asthma control (63–65). Some independent risk factors may be
identified from bioinformatics, that is, the use of mathematical
tools to extract useful information from large datasets (e.g.,
Reference 66). In short-term studies, where long-term risks are
not be able to be recorded, some outcome measures can be used
as surrogate markers for change in future risk.
Validation of Measures of Asthma Control
Because there is no gold standard for the definition of asthma,
there can be no gold standard for the assessment of asthma
control, and no single primary endpoint can be recommended
for the assessment of treatment response in asthma. The four
components of the definition of asthma (symptoms, airway
obstruction, airway hyperresponsiveness, and airway inflamma-
tion) are only loosely associated (67–70), so no one of these
domains is completely suitable as a comparator for validation of
individual measures of asthma control.
The comparator for validation of asthma control measures
has often been a ‘‘global physician assessment,’’ but this may
not provide an absolute standard (71). In the past, global
physician assessments were probably based largely on the
patient’s recent clinical status (symptoms, night waking, reliever
use, exacerbations) as recommended in clinical practice guide-
lines (8), together with factors such as the extent of patient
‘‘bother’’ (72). The shift in recent guidelines (9) to explicitly
incorporate future risk into the assessment of asthma control
may lead to a subtle change in physician global assessments in
years to come. At present, there are no firm guidelines as to
how physicians should integrate the dual components of current
control and future risk into an overall assessment of asthma
control, either in clinical practice or in clinical trials.
Asthma-related quality of life is a global measure of the
impact of asthma from the patient’s perspective and has been
used for validation of some of the measures examined in this
document. The patient’s own assessment of their level of asthma
‘‘control’’ will depend on their ability to detect airway obstruction
(73), as well as their personal interpretation of the term
‘‘control.’’ This may differ markedly from that of the clinician (6).
In asthma, response to treatment is not an absolute charac-
teristic. It depends on the baseline status of the study popula-
tion (including phenotype), the mechanism of action, dose and
duration of treatment, and the properties of the outcome
measure itself. A medication may lead to a response in one
domain of asthma or one phenotype, and hence in some
outcome measures but not others. For example, early clinical
trials of anti–interleukin-5 showed a profound reduction in
eosinophils but no effect on AHR (74). The insight into
pathophysiologic mechanisms that was provided by this and
similar studies highlights the benefit of assessing more than one
domain of asthma in clinical trials.
66 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
Range of Asthma Control
Asthma control is best considered as a scale or continuum; that
is, one should not refer to ‘‘achieving asthma control’’ to imply
achieving good control (6). In the past, the level of control has
often been categorized using semi-quantitative descriptors such
as ‘‘total,’’ ‘‘good,’’ or ‘‘poor,’’ or using relative terms ranging
from ‘‘best achievable’’ or ‘‘optimal’’ at one end of the contin-
uum, through ‘‘sub-optimal,’’ to ‘‘undesirable’’ or ‘‘unacceptable’’
at the other end. However, such descriptors involve arbitrary
cut-points, and so continuous or ordinal measures are preferred.
If categorical descriptors are needed (e.g., to describe study
populations at baseline), they should be based on clinically
meaningful cut-points.
Descriptors of asthma control such as ‘‘acceptable’’ beg the
question of whose perspective is being considered, the patient’s
or the physician’s, and whether the cost (financial and/or drug-
related side effects) of achieving the desired level of control has
been considered. The primary perspective for the assessment of
asthma control is that of the patient. However, the level of
control that may be acceptable to one patient may be unaccept-
able to another or to a clinician. In each case, ‘‘acceptability’’ of
the patient’s current clinical state needs to be balanced against
the future risk of either poor control or of treatment-related
adverse effects, and patient-reported measures should be sup-
plemented by the (objective) measures that relate to the
pathophysiologic domains of the definition of asthma.
Time as a Factor in the Assessment of Asthma Control
A patient’s level of asthma control may vary over relatively
short time intervals (days to weeks) in response to allergens or
infectious agents, or in response to treatment. The time-course
of improvement with treatment varies according to the partic-
ular outcome variable being measured (Figure 1) and according
to the type of treatment (e.g., ICS versus LABA). Therefore, in
cross-sectional studies, the relationship between different meas-
ures will vary according to the time of assessment. The order of
reappearance of different clinical features during an exacerba-
tion or after cessation of ICS also varies (30, 75).
In clinical trials, asthma control is assessed at defined points
in time, and some variables are suited to such interval mea-
surement. To be clinically relevant, variables such as symptoms
must relate to a meaningful recent period (76), rather than just
at the moment of assessment. By long-standing consensus,
clinical asthma control is usually assessed over periods of 1 to
4 weeks; this approach is supported by empirical data (77).
Applicability of Control Measures to Clinical Trials
Some outcome measures are used to assess whether a particular
intervention was active in relation to its specific pharmacologic
target. However, for interventions targeted at overall asthma
control, it is clearly desirable for outcome measures and
surrogate markers to be relevant to more than one therapeutic
intervention. Based on experience with antiinflammatory ther-
apy, it is often assumed that future risk of exacerbations will
directly parallel changes in current clinical control. However,
these two aspects are not necessarily concordant, particularly
with LABA monotherapy (41, 61), or even with combination
ICS/LABA (78). Such discordance (between current clinical
control and future risk) should be considered in the evaluation
of other therapies (e.g., a therapy aimed at reducing rhinovirus
infections may reduce exacerbations without changing the
level of clinical control). Hence, given that the goals of asthma
treatment relate to both the achievement of good control and
the minimization of future risk, it is not appropriate to specify
a single primary endpoint for the assessment of asthma
2009
Figure 1. Time-course of improvement in different asthma control
outcome variables with inhaled corticosteroid treatment. Reprinted
with permission from Reference 418. This figure was constructed with
data from Reference 26; the statistical analysis of time to plateau
is described in Reference 122. AHR 5 airway hyperresponsiveness;
SABA 5 short-acting b2 agonist.
control. Studies of clinical efficacy and effectiveness should
use appropriate endpoints which capture both aspects of
asthma control.
Analysis of Asthma Control in Clinical Trials
There may be situations in which it is appropriate to assess the
‘‘end-of-treatment’’ level of control (e.g., if the study hypothesis
focuses on the proportion of patients who meet a certain
criterion after a specified period of treatment). However, in
general, it is preferable to assess the level of asthma control
throughout the study. Analysis of data drawn from over the
whole treatment period will reflect the magnitude and rate of
treatment response, the extent of variation in level of control,
and the occurrence of exacerbations, all of which are relevant to
the overall impact of treatment on asthma control. This will
typically include assessment at each study visit, or, for diary
measures, over multiple periods each of 1 to 4 weeks. The
resulting multiple data points for each patient can be analyzed
by mixed model (or equivalent) analyses, which are to be
preferred over merely averaging the data over the whole
treatment period, to improve the power of the study.
DIARY DATA IN THE ASSESSMENT OF
ASTHMA CONTROL
Symptoms and airway obstruction are integral to the definition
of asthma, and represent important components of the assess-
ment of asthma control in clinical practice and clinical trials.
However, symptoms are highly variable, and interval question-
naires, administered at clinic visits, are limited by patient recall
(79) and by the improved medication adherence that is seen in
the weeks before and after a clinic visit (80). Airway obstruction
is also characteristically variable in asthma, and clinic lung
function, if measured after withholding of study medication,
does not represent the patient’s usual daily on-treatment state.
Therefore, it can be advantageous to use diaries to record
outcome variables during the subject’s normal day-to-day life,
or to identify the time-course of change with treatment.
However, short-term diaries, used for 1 to 2 weeks before clinic
visits, may not provide more information about symptoms than
can be obtained from clinic-based questionnaires (81). Adher-
ence is a major issue with long-term diaries (49), but high rates
of adherence can be achieved with user-friendly electronic
diaries (82). Diaries can also be used for recording adverse
events, interference with activities, and health care utilization
(83, 84).
American Thoracic Society Documents
Methods of Recording Diary Data
Most published diary data have come from paper diaries and
mechanical PEF meters. The introduction of electronic devices
allowed covert assessment of such records, and the universal
finding, in asthma as in other diseases, was that a substantial
proportion of data in paper diaries was fabricated or completed
retrospectively (49). Electronic devices are now being intro-
duced for routine collection of time-verified diary data in
clinical trials (85–87), under draft guidance provided by the
FDA. Electronic diaries enhance data quality (88, 89), and can
improve adherence with monitoring (82), which should sub-
stantially reduce sample size requirements (90). Electronic
recording reduces time to database lock (86). These benefits
must be weighed against equipment costs, which may be sub-
stantial. In addition, careful attention must be paid to reliability
of equipment and software, user-friendliness, rapid technical
support, regulatory requirements, and practical issues such
as after-midnight entries, travel across time zones, and shift
work (86, 88, 89). In a meta-analysis, paper- and computer-
administered versions of patient-reported outcomes were found
to be equivalent (91).
Diary Questions
Symptom monitoring. Asthma symptoms are nonspecific, and
their occurrence and perception varies between patients. We
found a wide range of symptom score scales ranging between 0–
3 and 0–12, with or without text descriptors, with most studies
distinguishing between daytime and night-time symptoms and
night-waking. To encompass the range of asthma symptoms,
some diaries asked about ‘‘asthma symptoms’’ without further
definition. In others, individual symptoms such as wheeze,
shortness of breath, and cough were recorded separately. The
more questions about individual symptoms, the less likely
a patient is to satisfy criteria for a symptom-free day or good
asthma control (92). Diaries variously ask for frequency, in-
tensity, and/or impact of symptoms on normal activities without
distinguishing between them; we did not find any publications
that compared the responses to these three symptom domains.
For children, diary completion by parent/caregiver rather
than child may result in a more complete dataset, but may lead
to underreporting (93). Symptom reporting by parents depends
on many factors, including the type of scoring scale (94) and
whether the parent smokes (95). Doctors and parents often
disagree about the presence of wheeze (96, 97). An interesting
option in pediatric studies is the use of pictorial symptom
diaries to allow self-completion by the child (98).
Diary-derived symptom variables have been reported in
many different ways (99). The most consistent, in both adult
and pediatric studies, is the proportion of symptom-free days
(100), or, conversely, the number of symptom-days per week
(16); this links with guidelines criteria for well-controlled asthma
(8, 9). To ensure consistency between studies, ‘‘symptom-free
days’’ should be established specifically from a question about
‘‘asthma symptoms.’’ Although simple to assess, ‘‘symptom-free
days’’ are insensitive to change in either very mild asthma, in
which there is limited scope for improvement, or in more severe
asthma, in which patients may experience symptoms every day.
Reporting group mean differences for individual symptom
scores may be better in such populations. Scores for different
symptoms are often combined into mean or cumulative scores,
either for day and night separately or as a ‘‘total asthma
symptom score’’ (101), but there is little standardization.
Reliever use. Use of quick-acting b2-agonists may reflect the
frequency and intensity of symptoms, the patient’s symptom
tolerance, the usual level of physical activity, and the duration of
67
action of any routinely taken b2-agonist (usually a LABA). In
clinical trial reports, b2-agonist use is usually quantified as the
number of inhalations or puffs/day, or as reliever-free days.
However, the routine dose of some b2-agonists is one inhalation,
and for others, two inhalations (and even for the latter, some
patients may routinely use one inhalation). To reduce this
heterogeneity, we recommend that b2-agonist use should be
recorded as ‘‘occasions’’ rather than ‘‘puffs’’ per day. Diary
instructions should clearly explain the difference. Patients may
interpret ‘‘times per day’’ as meaning either ‘‘puffs’’ or ‘‘occa-
sions,’’ so this wording should also be avoided.
Some b2-agonist use is anticipatory (e.g., to prevent exercise-
induced asthma). This may be reflected in a lower proportion of
b2-agonist–free days than symptom-free days (33, 102). Some
studies exclude b2-agonist use before exercise (103) and others
report it separately (104). We recommend that use of b2-agonist
for relief of symptoms should be recorded and reported
separately from prophylactic use.
In childhood asthma, rescue medication use is often con-
trolled by the parent (105), and this may produce discrepant
reports. In a pediatric study, little relationship was found
between electronically recorded SABA use and symptom
severity score (106). It is unclear whether supervised rescue
medication gives a better assessment of asthma control than
medication taken without involvement of a parent. Hence, both
symptoms and b2-agonist use should be reported.
b2-agonist use provides a continuous numerical measure of
asthma control, but reporting presents some challenges. Daily
b2-agonist data are usually right-skewed, but daily medians may
conceal intermittent heavy usage (e.g., if a subject uses b2-
agonist on 8 occasions/d for 3 d each week, median usage is still
0 occasions/d). Reporting mean daily usage (total occasions in
one week/7) is an improvement, but cannot distinguish between
intermittent heavy use and daily low-frequency use. Hence, we
recommend reporting of both the proportion of reliever-free
days and the mean of occasions per day, the latter averaged
over 1 week.
Validation of symptom and reliever diaries. As diaries are
a special form of questionnaire, they should be subjected to the
same validation procedures as interval questionnaires, but this
has rarely been done. Clinical trial outcomes may be dramat-
ically affected by even minor differences in the wording and
criteria for diary measures (23), so standardization is important.
Some studies have validated patient diaries against interval
clinic questionnaires, but the latter are limited by patient recall.
The same problem applies to using physician global assessment
as the comparator, as this too is heavily influenced by patient
recall of symptoms and reliever use. If electronic diaries are
available to avoid recall errors, clinic questionnaires could be
validated against daily records rather than vice versa.
Santanello and colleagues have published validation studies
for asthma diaries for adults (83), and children aged 6 to 14 years
(85). The adult diary showed good internal consistency and
reproducibility in two placebo-controlled trials. Longitudinal
associations were stronger for average daily PEF than for weekly
clinic FEV1 (83). The daytime pediatric diary had acceptable
longitudinal construct validity against physician assessment and
quality of life in stable and unstable patients (85). Juniper and
colleagues developed and validated a daily diary from the
Asthma Control Questionnaire (ACQ), and found that its
measurement properties over a single week were similar to those
of the ACQ itself, recorded at the end of the same week (82).
Responsiveness. Despite the poor quality of data from paper
diaries, diary measures have shown significant treatment
responses at a group level in many asthma studies. ‘‘Symptom-
free days’’ have generally shown good responsiveness in subjects
68 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
with frequent symptoms at entry (16, 26, 107, 108), but this
variable is limited by a ‘‘ceiling effect’’ for patients with mild
asthma and a ‘‘floor effect’’ for patients with severe asthma.
Responsiveness testing of the Santanello diaries was limited by
the limited efficacy of the study medication on the comparator
variable (FEV1) (86). For validation of the ACQ diary, physician
assessment was used as the comparator, and hence responsive-
ness, not surprisingly, favored the clinic questionnaire recorded
on the same day as the physician assessment (81).
With ICS treatment, the time-course for change in symptoms
and reliever use is rapid, with statistically significant reductions
in less than 1 week (26, 109). Night-waking resolves rapidly,
with daytime symptoms and reliever use continuing to improve
for up to 71 months (26) (Figure 1).
Minimal important difference. Assessment of minimal impor-
tant change in diary variables is limited by the choice of
comparator. Minimal important differences have rarely been
reported for symptom scores, with most papers merely reporting
statistically significant changes in mean scores. Santanello and
coworkers reported the minimum patient-perceivable improve-
ment in symptom score (scale 0–6, baseline 3) as 20.31, and in
reliever use as 20.81 puffs/day (baseline 5.4 puffs/d) (110). For
the composite ACQ diary score, a change of 0.5 (scale 0–6,
baseline 1.5) was reported as clinically important (111).
Ambulatory Lung Function
Ambulatory recording of PEF or FEV1, or both, provides an
objective day-to-day measure of airway obstruction, and is one
of the most commonly-reported physiologic outcome variables
in clinical trials. Safety has been established, with low rates of
maneuver-induced bronchospasm (88, 112). With adequate
training, good within-session reproducibility can be achieved
for home PEF and FEV1 monitoring (88, 112), but PEF and
spirometric technique should be checked at every visit. Video
feedback has been used to improve maneuver quality (113).
Subjects should always be asked to complete symptom diaries
before measuring PEF, to avoid bias. Some studies exclude the
first 1 to 2 days’ data for training effect (114). In children, even
with careful training, results from home spirometry are in-
consistent (115), so ambulatory lung function monitoring has
little role in studies in children.
There are no standardized methods for recording ambula-
tory spirometric data, but basic guidelines for laboratory-based
testing can be applied (116). The exception is that maneuver
selection should not be based on the highest FEV11FVC, since
FVC from unsupervised maneuvers may not be as reliable as
FEV1 (88). The highest value from three maneuvers is usually
analyzed. Most published studies have used morning recordings
either on arising or within a specified time-window (e.g., 6:00–
8:00 A.M.). However, use of time-windows may increase rather
than decrease heterogeneity, as diurnal changes depend more
on hours since waking than on the time of day (117). To obtain
a more stable measurement, patients are usually asked to record
PEF before taking routine study medication, and preferably
before reliever medication, but, by contrast with interval clinic
spirometry, it is not appropriate to ask patients to withhold as-
needed b2-agonist (118).
In clinical trials, the most commonly-reported diary lung
function variable is mean morning PEF. From basic statistical
principles, analysis of PEF as L/minute, adjusted within the
statistical model for the patient’s age, height, sex, and race, is
preferred over analysis as % predicted, so that the relationship
between these factors within the study population will be
modeled on the actual data rather than fixed by a reference
equation derived from other populations. However, for charac-
terization of the study population at baseline, lung function data
2009
are most usefully reported as % predicted, with the source of
the reference equations stated.
Responsiveness. Ambulatory lung function is highly respon-
sive to ICS or LABA treatment, with morning PEF more
responsive than evening PEF (118, 119), and morning and
evening PEF more responsive than morning and evening FEV1
(26). With ICS, significant between-group differences can be seen
as early as 1 to 4 days (26, 119, 120). With electronic spirometric
monitoring, significant between-group differences can be seen
even in very mild asthma, where no differences in symptoms are
detectable (121). Morning PEF continues to improve for around
2 to 3 months with ICS treatment (122, 123). Inclusion of PEF
data recorded after routine (15, 119) or as-needed (118) b2-
agonist use significantly reduces the apparent response to ICS.
Minimal important difference. Santanello reported the min-
imal patient-perceived improvement in PEF as 18.8 L/minute
(110) in patients whose baseline FEV1 was approximately 60%
predicted (124), but it cannot be assumed to be the same for
patients with better lung function. Most power calculations for
efficacy studies quote a clinically relevant difference for morn-
ing PEF of 15 or 20 L/minute, but the sample sizes calculated
for these studies have ranged from under 40 (125) to almost 200
(126) subjects per group. It is rarely possible to evaluate the
appropriateness of published sample sizes, as few papers report
the source of the data that were used in the calculations.
Peak Expiratory Flow Variability
Variation in lung function represents a different domain of asthma
control from static lung function, and both should be reported.
There are multiple different calculations of within-day variability
(diurnal variability) (127), but the most common is amplitude
percent mean (day’s highest minus lowest/mean), averaged over
7 days. With twice-daily PEF measurement, the upper limit of
normal for amplitude % mean (95% confidence limit for reference
population) is 8% (114) (9.3% in adolescents [127]), increasing to
19% when PEF is recorded more frequently (117). The frequently
cited cut-point for diurnal variability of greater than 20% for
diagnosing asthma or for classifying asthma as ‘‘persistent’’ (5, 8) is
not applicable to twice-daily monitoring. This criterion originated
from cosinor modeling of four-times-daily PEF data by patients
who had been selected for the presence of definite circadian
variability soon after an asthma hospitalization (128).
The most common method of calculation of between-day
PEF variability is the lowest PEF (or lowest morning PEF) over
1 or 2 weeks, divided by the highest PEF (8, 69, 123). This index
increases as PEF variation decreases.
The above calculations were designed for use in clinical
practice, but in clinical trials, PEF variability can also be assessed
by standard mathematical methods—for example, standard de-
viation (51, 129, 130) or coefficient of variation (131). Sophisti-
cated fluctuation analysis has shown associations between PEF
variability and risk of exacerbations (131).
Analysis of Diary Variables
In the past, treatment effect for diary variables has often been
evaluated by ANOVA or paired t tests of the average of the
whole treatment period (16) or the last 1 to 2 weeks of
treatment (132), with results usually reported as mean or
cumulative change from baseline (absolute or percent). How-
ever, more recently, mixed model analysis or generalized
estimating equations have been used, taking advantage of the
power provided by multiple data points per subject (133, 134),
and better representing asthma control over the whole treat-
ment period. Use of such statistical methods will reduce the
sample sizes required for clinical trials.
American Thoracic Society Documents
Clinical Associations
Although symptoms and lung function are commonly recorded
in clinical trials, associations between them are only rarely
reported (99). Symptom scores in adults and children generally
have moderate or weak correlations with other asthma out-
comes, including static lung function, PEF variability, airway
reactivity, and airway inflammation (69, 70, 123, 135), consistent
with the fact that these represent different domains of asthma
control. The lack of correlation may also partly be due to the
lack of specificity of asthma symptoms, and to differences in the
magnitude and time-course of the response to treatment (26).
Increased PEF variability has been found to be associated
with an increased risk of exacerbations (19, 131). Innovative
fluctuation analysis of serial lung function measurements is very
promising with regard to the prediction of exacerbations,
independent of mean PEF (131). This is fueling renewed
interest in ambulatory monitoring of PEF and FEV1 in asthma.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL TRIALS
1. Diaries are useful to assess asthma control in any clinical
trial in adults and children, and for patient characteriza-
tion before randomization, to avoid the problems of
patient recall and the effects of change in medication
adherence that affect interval questionnaires.
2. Given the evidence for the superiority of data from
electronic compared with paper diaries, electronic di-
aries should be preferred in principle to improve data
quality. However, technological reliability and user-
friendliness must be ensured. To enhance adherence,
participants should be made aware of the recording
capability of the device. Given the difference in data
quality, electronically collected data should be clearly
identified in abstracts and papers.
3. Diaries should be designed at an appropriate reading
level, and with features that will optimize adherence by
minimizing the burden of monitoring.
4. The use of standardized diaries that have been for-
mally validated in an appropriate population of indi-
viduals with asthma (mild or severe, adult or pediatric,
self-completed or caregiver-completed) should be pro-
moted.
5. Diaries should include questions on asthma symptoms,
night-waking due to asthma, and reliever use. Ques-
tions about symptom frequency, intensity, and impact
are not interchangeable. The actual wording of diary
questions (in the original language) should be provided
with all clinical trial reports.
6. ‘‘Symptom-free days’’ is a useful diary variable, but
may not be sufficiently responsive in study populations
with either very frequent or infrequent symptoms. This
variable should be derived from a general question
about ‘‘asthma symptoms,’’ rather than from several
questions about individual symptoms.
7. Diary instructions should advise patients how to record
b2-agonist use. Use of b2-agonist other than for relief
of symptoms (e.g., before exercise) should be recorded
and reported separately. Reliever use should be
69
reported both as the proportion of reliever-free days
(5 b2-agonist free days) and as the mean of occasions
(not puffs) per day, averaged over 1 week.
8. Ambulatory recording of lung function (FEV1 and/or
PEF) is used in some studies to provide information
complementary to that provided by symptom diaries or
clinic FEV1. Mean morning PEF provides information
about current clinical control, and peak flow variability
provides independent information about risk of future
exacerbations.
9. In clinical trials, where data are analyzed electronically,
standard statistical methods of assessing variability are
preferred to previous methods such as amplitude percent
mean.
10. Where feasible, diary data should be collected and
analyzed over the whole treatment period to capture
asthma control over a longer interval. Methods of analysis
such as mixed model and generalized estimating equa-
tions should be used where possible, to maximize the
power of the study and increase the information that is
obtained about asthma control between clinic visits.
These points are also applicable for clinical trials in primary
care. In addition, in primary care:
d Standardized diaries, suitable for the diverse and often
milder patient populations should be validated for clin-
ical trials.
d Symptom-free days may not be an appropriate outcome
measure in primary care studies due to lack of sensitivity
in mild asthma.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL PRACTICE
1. Symptoms and lung function represent different domains of
asthma, and they correlate poorly over time in individual
patients, so both need to be monitored by clinicians assess-
ing asthma control in clinical practice.
2. Long-term diaries are not needed for the clinical man-
agement of asthma in the majority of patients, but may be
relevant in ‘‘poor perceivers’’ (patients who have difficulty
sensing airway obstruction) or patients with frequent
exacerbations.
3. When patients are carrying out ambulatory lung function
monitoring, their monitoring device should also be used
for testing in the doctor’s office, to allow comparison with
their usual readings.
4. Lung function diary monitoring is to be encouraged in the
diagnosis of asthma. The upper limit of normal for am-
plitude percent mean with twice-daily monitoring is 8%,
not the traditionally quoted cut-point of 15 to 20%.
PEDIATRIC ISSUES
1. Pediatric studies should use diaries specifically validated
for this age group.
2. In pediatric studies, as in adult studies, paper diaries are
subject to poor adherence and data fabrication.
70 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
3. For children less than 12 years of age, diary completion by
caregiver rather than child may result in a more complete
dataset, but may introduce bias. Use of pictorial symptom
diaries may allow self-completion by the child.
4. Ambulatory lung function monitoring has little role in
studies in children.
RESEARCH QUESTIONS
1. Data are urgently needed on internal consistency and
test-retest reproducibility of diary measures, and their
correlation with other asthma outcomes, to develop a suite
of diary forms, questions, and scores for different pur-
poses (mild or severe asthma, pediatric or adult, parent-
completed or child-completed, long-term or short-term
use).
2. Minimal important differences need to be defined and
quantified, to allow for power calculations if diary varia-
bles are used as primary endpoints. Underpinning this
work, there needs to be analysis of the extent to which
various measures of asthma control predict future risk to
the patient.
3. Identification of ways to optimize adherence with diaries,
particularly for long-term studies, deserve priority.
4. There is an urgent need for reliable low-cost user-friendly
electronic devices and interactive internet-based software,
for both symptom and lung function diaries, to eliminate
data fabrication and obtain more reliable information
about the relationship between diary measures and other
variables.
5. Fluctuation analysis of serial measurements of ambulatory
PEF or FEV1 deserves further development and validation
in relation to the prediction of disease outcomes.
LUNG FUNCTION AND AIRWAY
HYPERRESPONSIVENESS
Spirometry
Measurement and analysis. Based on the definition of asthma
and the goals of treatment (8, 9), spirometry is one of the
fundamental measures of asthma control. It provides an objec-
tive and highly reproducible measure of airflow limitation
caused by smooth muscle contraction or structural changes.
The main spirometric parameters relevant to asthma are FEV1,
FVC (as VC or FEV6), FEV1/FVC ratio, bronchodilator (BD)
responsiveness (change in FEV1 after inhaled bronchodilator),
and post-BD spirometry.
For clinical trials, pre-BD FEV1 is defined as FEV1 recorded
after withholding of SABA and LABA for a period appropriate
for their duration of action (e.g., > 6 h for SABA and > 12 h for
LABA). Pre-BD FEV1 has been used as the primary endpoint
of lung function in the majority of asthma clinical trials over the
last three decades. This had its origins in the early focus on
airway obstruction as the primary characteristic of asthma. Pre
BD FEV1 is influenced by short-term fluctuations in airflow
limitation and therefore can be considered as a measure of
asthma control. Adherence to methods recommended by ATS/
ERS (136) minimizes the effect of patient effort. Elderly
patients can perform spirometry with good quality (137).
Specific ATS/ERS guidelines are available for preschool chil-
dren (138).
2009
Post-BD FEV1 is defined as FEV1 recorded 15 minutes after
administration of 400 mg albuterol or equivalent. It is not
considered necessary to specify whether LABA or study
medication should be withheld, as FEV1 is close to plateau
levels after 400 mg albuterol. Post-BD FEV1 values are likely to
be determined by airway structure and may be used as
a measure of severity in describing certain asthma phenotypes.
Both pre-BD and post-BD FEV1 may change with treatment
that modifies underlying disease activity. In clinical practice,
lung function recordings are usually made without withholding
of regular controller medications. The resulting ‘‘on-treatment
FEV1’’ will only be significantly different from ‘‘pre-BD FEV1’’
for patients taking LABA. To standardize the measurement of
‘‘on-treatment’’ FEV1, it should be performed after withholding
SABA appropriately.
For clinical trials, a more stringent goal for within-test
reproducibility of FEV1, of less than or equal to 100 ml, should
be considered than the 150 ml recommended by ATS/ERS for
general use (136). The most appropriate spirometry outcome
variable is pre-BD FEV1, adjusted for baseline. Its methodology
has been carefully standardized, and its measurement allows
comparison of the study population with most other studies, as
it has been by far the most commonly reported outcome
variable in asthma studies to date. As indicated above, for
morning PEF, spirometric outcome variables for adults and
children/adolescents should primarily be analyzed as absolute
data (adjusted for age, sex, and height) rather than as percent
predicted. In long-term studies (. 12 mo) in children under age
18, the model should include adjustment for height at each visit .
The analysis of spirometric data from serial visits may in-
corporate mixed model analyses, or calculation of FEV1 area-
under-the-curve to take advantage of multiple datapoints.
Change in BD responsiveness has been reported in a small
number of asthma clinical trials, but is not recommended as an
endpoint because of a ‘‘ceiling effect,’’ especially if pre-BD spi-
rometry is near the participant’s personal best value. In addition,
any calculation of change doubles the variance in a measurement.
Reference values and reproducibility. Reference values for
percent predicted FEV1 and/or FVC are primarily used for
inclusion or exclusion criteria for clinical trials (139), and to
characterize the study population. This allows comparison with
other studies, which may have a different balance of sex and
age. Percent predicted values should not be used as outcome
variables (139), except as above in long-term pediatric studies.
The ATS/ERS 2005 guidelines (140) recommend ECSC refer-
ence values for Europe (141) and NHANES III reference
values for North America (142), including Hispanic values that
are also suitable for Central and South America (143). For each
lung function index, the lower limit of the normal range is
defined by the fifth percentile.
The short-term (, 1 h) within-subject reproducibility for
FEV1 and FVC is very good: less than or equal to 200 ml and
5% for both healthy subjects and patients with asthma (all ages)
(144, 145). Values within these limits are indicative of acceptable
biological and technical variability. Asthma is characterized by
variable airflow limitation, so, as expected, the visit-to-visit
reproducibility of FEV1 (without an intervention) is signifi-
cantly better in healthy subjects than in asthma (146). However,
although intuitively one might anticipate it, there are few data
to confirm that between-maneuver variability in FEV1 corre-
lates with overall asthma control.
Responsiveness and time scale. Based on within-subject re-
producibility, an improvement in FEV1 of greater than or equal
to 12% and 200 ml in patients with asthma with baseline airway
obstruction is usually considered to be significant (140). In
clinical trials, this level of improvement with bronchodilator is
American Thoracic Society Documents
often pre-specified by study inclusion criteria, to provide
objective confirmation of the diagnosis of asthma (139). FEV1
is more responsive than FVC, since FVC is usually even closer
to its normal or maximal value. Although baseline clinic FEV1
is often within the normal range in patients with mild or well-
controlled asthma (147–149), a ceiling effect for responsiveness
of FEV1 is not necessarily seen in adult populations (121, 150).
The FEV1 responds to fast-acting inhaled bronchodilators
within ten minutes, this effect lasting for at least two hours (151).
The FEV1 also responds to slower onset inhaled bronchodilators
(salmeterol and anticholinergics) within about an hour (152).
Both pre-BD and post-BD FEV1 increase within days with ICS
(26) or prednisone therapy, and the improvement lasts for days
to weeks after discontinuing chronic ICS therapy (153). Mea-
surement of post-BD FEV1 over many years is recommended
for monitoring growth and decline in lung function, because it
is less affected by variability in smooth muscle tone. Although
post-BD FEV1 does not give direct information about airway
structure, it is the recommended functional measure when airway
remodeling is the focus of interest (154, 155).
The minimal important difference (MID) for improvement
and worsening in FEV1, based on patient perception of change,
is about 10% (110, 156), but this is not well established. This
difference is greater than the expected test-retest variation
(140).
Associations with other asthma control measures. Airflow
limitation is a major cause of dyspnea and chest tightness, but
FEV1 and symptoms are only weakly associated in asthma. In
cross-sectional analysis, for example at study entry, pre-BD
FEV1 (% predicted) has been associated with most other
measures of asthma control (3, 61, 157). However, correlations
with symptoms are usually weak (158–161), and correlation with
disease-specific quality of life is poor (162, 163). Longitudinal
changes in FEV1 have also been associated with changes in most
other asthma outcome measures (164–166). However, again,
such associations are generally poor, including those with
indices of airway inflammation (167).
For assessment of future risk, low pre-BD FEV1 percent
predicted (66, 168, 169) or low on-treatment or random FEV1
percent predicted (170–172) are strong, independent predictors
of subsequent asthma exacerbations. Bronchodilator reversibility
is also an independent predictor of death due to asthma (168).
These findings indicate that spirometry provides comple-
mentary information that is not provided by other outcome
variables (3, 173). Indeed, improvement in symptoms using, for
example, LABA therapy, may occur without any change in pre-
bronchodilator FEV1 (61). Change in FEV1 is also moderately
associated with change in PEF (174). Bronchodilator respon-
siveness is only weakly associated with measures of AHR and
airway inflammation, but is an independent predictor of re-
sponse to ICS therapy (156, 175). However, most clinical trials
have not published these associations (even when they were
determined).
Peak Expiratory Flow
PEF is inferior to FEV1 as a clinic-measured parameter of
airways obstruction as it confers no advantage in reproducibil-
ity, lacks accurate reference values for many populations, and
may underestimate airway obstruction in individuals with
airway remodeling. Where serial office PEFs are recorded, the
same instrument should be used on each occasion if possible.
PEF measurement is most suitable for ambulatory monitoring
for within-patient comparisons over time, although, with com-
pact electronic devices, daily home monitoring of FEV1 has
become a realistic and successful alternative to this (121) (see
71
AMBULATORY LUNG FUNCTION). Interest in ambulatory lung
function monitoring has been renewed by innovative fluctuation
analysis which has been found to predict clinical course (131)
(see DIARY DATA IN THE ASSESSMENT OF ASTHMA CONTROL: PEAK
EXPIRATORY FLOW VARIABILITY).
Lung Volumes and Airway Resistance
Very few asthma clinical trials have used pulmonary function
tests other than spirometry or bronchial challenge testing as
endpoints. While hyperinflation contributes to sensations of
dyspnea and chest tightness during asthma exacerbations or
exercise (176), there is no convincing evidence to date that
measuring reductions in RV or FRC adds clinically important
information to the increases in FEV1 or FVC that occur
simultaneously with successful therapy.
Airway resistance is increased during asthma exacerbations
and falls with successful asthma therapy. It can be measured
with body plethysmography or other instruments (forced oscil-
lator or interrupter technique). Advantages of airway resistance
measurements over spirometry include: (1) strenuous breathing
maneuvers are not needed, (2) the effects of deep inspiration
are eliminated (177), and (3) results can be obtained from
preschool aged children (178, 179). Methods for the forced
oscillator technique (FOT) have been standardized by the ERS
(180). However, airway resistance tests have some disadvan-
tages, including equipment costs, few validation studies, the
need for trained technologists, and the lower signal–noise ratio
compared with FEV1 measurements (181).
Airway Hyperresponsiveness
Method and parameters. Airway hyperresponsiveness (AHR) is
an objective, well-standardized measure of variable airflow
limitation. It reflects the increased sensitivity of the airways to
inhaled stimuli, a problem reported by the majority of patients
with asthma, even when spirometry is normal. It can be
measured by ‘‘direct’’ and ‘‘indirect’’ challenge tests (182,
183), which refer to the mode of action of the agents in relation
to smooth muscle contraction. Methacholine chloride and
histamine diphosphate are most commonly used as direct
smooth muscle stimuli, but the results cannot be used inter-
changeably (182, 184). Currently, the most frequently used
indirect stimuli, which involve multiple cellular pathways, are
hypertonic saline, adenosine monophosphate (AMP), and man-
nitol (182, 183, 185).
Guidelines for challenge testing have been published by the
ERS (182) and ATS (184). There are two safe and validated
methods for inhaling aqueous solutions of pharmacologic
stimuli. These are the 2-minute tidal breathing method (182–
184), and the dosimeter method (182–184). These methods are
both well standardized, but they cannot be used interchange-
ably (186). New commercially available dosimeter methods
are emerging, and may offer an alternative provided that the
methodology is validated against the two gold standards
above.
Regardless of the method, only the first part of the sigmoid
log concentration or log dose–response curve can be recorded.
The curve is usually expressed by its position: the provocative
concentration/dose (PC or PD) to cause a certain degree of
airway narrowing (e.g., 20% fall in FEV1: PC20, PD20) as
measured by log-linear interpolation (182, 183). It is customary
to use PC20 for the tidal breathing method, and PD20 for the
dosimeter method (although the dose delivered to the airways
can only be roughly estimated). A 20% fall in FEV1 can often
not be obtained in control subjects without asthma, for which
the so-called ‘‘two-point slope’’ method is a valid alternative
72 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
(187). Extrapolation of dose–response curves is strongly dis-
couraged. In young children, measurement of respiratory re-
sistance may be an alternative to FEV1 during challenge testing.
This needs further validation (138, 188).
Challenges are safe when the protocols comply with current
recommendations (182–184), and are well tolerated even in
young children (138, 189). Detailed standardized laboratory
operating procedures should be at hand. Compulsory safety
precautions (182–184) must be obeyed at all times.
Reference values and reproducibility. The normal range of
PC20 for both methacholine chloride and histamine diphosphate
is greater than or equal to 8 mg/ml (190), while for PD20 it is
greater than or equal to 7.8 mmol for both agents (191). The
normal range of two-point slope to methacholine has been
reported to be less than 2.39% fall/mmol, but appears to be
a function of age and pre-test FEV1 (192). The normal range of
PC20 for AMP has been suggested to be greater than or equal to
200 mg/ml (193). The PC20 and PD20 are adequately described
by their geometric mean values and geometric standard devia-
tions (expressed in doubling concentration or dose, respec-
tively).
The 95% confidence interval for short-term repeated meas-
urements of PC20 and PD20 for histamine and methacholine is 6
1.5 doubling dose (182), and for AMP 6 1.7 doubling dose
(194). The intraclass correlation coefficient for repeated mea-
surement of the two-point slope to histamine is only 0.26, but
can be improved by calculating the slope by least-square
analysis (195). Recommendations for sample size estimations
based on PC20 and PD20 are available (196).
Responsiveness and time-scale. Bronchial challenge tests are
immediately responsive to pretreatment with functional antag-
onists, such as short-acting (197) and long-acting (198) b2-
agonists. Short-acting bronchodilators should be stopped 8 hours
and LABA 36 hours before the test (182–184). Even after
withholding of salmeterol for 24 hours, there is still a greater
than twofold shift in PC20 (198). In clinical trials, the impact of
these drug-free intervals on the measurement of other outcome
variables needs to be considered.
Challenge tests are highly suited for monitoring therapy
aimed at disease modification, such as antiinflammatory
therapy. Increases in PC20 and PD20 with ICS are dose- and
time-dependent. Meta-analyses show on average 0.9 dou-
bling dose improvement in short-term studies (2–8 wk) (199),
with greater improvements by high-dose (. 1,000 mg/d
beclomethasone equivalent) versus low/medium doses ICS
(, 1,000 mg/d) (200). Longer term studies have demonstrated
much larger average improvements in PD20, reaching 4
doubling doses (16.5-fold change) after 18 months of treat-
ment (26).
The time-scale of changes in PC20 and PD20 in response to
ICS therapy varies with the challenge agent. The improvement
in PD20 to histamine in adults and to methacholine in children
did not show a plateau after 18 months and 22 months of
therapy, respectively (26, 201). Inhaled corticosteroids have
a much more rapid onset of action when measured by direct
challenges such as AMP as compared with methacholine
challenge (202, 203). This illustrates that indirect challenges
are somewhat more closely dependent on the acute state of
inflammatory pathways in the airways (203), whereas methacho-
line responsiveness additionally appears to be determined by
airway dynamics and structure (204). This distinction can be
important when monitoring long-term therapy.
Clinically relevant differences. During seasonal allergen ex-
posure (205) or after respiratory virus infection (206), group
averages of change in PC20 or PD20 of at least 1 doubling dose
have been observed. As indicated above, PC20 or PD20 respond
2009
to ICS on average by at least 0.9 doubling dose after short-term
treatment (199), while responses less than 1 doubling dose were
labeled as ‘‘poor’’ in a multicenter study aimed to compare
responsiveness of clinical markers to ICS in asthma (156). These
data provide an indicative rather than validated estimate of
clinically relevant differences.
Association with other markers and disease outcome. Airway
hyperresponsiveness has a high negative predictive value for the
diagnosis of asthma (207, 208). However, in cross-sectional
studies, AHR is only weakly associated with symptoms, lung
function, and markers of airway inflammation (3). This may be
its strength, because it provides independent and complemen-
tary information (209). Therefore, AHR is neither a surrogate
for clinical symptoms nor for airways inflammation.
Longitudinal studies, mostly performed with direct challenge
agents, have demonstrated that hyperresponsiveness is strongly
related to the clinical course of asthma. In young infants it can
predict the development of asthma later in life (210). As
a predictor of future risk, increased hyperresponsiveness pre-
dicts loss of control in children (211) and adults (212) with
asthma, and appears to be a significant and independent risk
factor for the development of irreversible loss of lung function
(213–215). Even asymptomatic AHR in the general population
appears to be a significant risk factor for subsequent develop-
ment of wheeze, physician-diagnosed asthma, chronic cough,
chronic bronchitis, and COPD (216).
With regard to treatment monitoring, baseline AHR to
methacholine predicts the spirometric treatment response to
ICS of individuals with asthma (217). Interestingly, individu-
alized treatment additionally guided by AHR to methacho-
line leads to fewer uncontrolled episodes in adults with
asthma (39). This suggests that AHR is an indirect but
meaningful marker of asthma control. In the same way,
AHR-guided therapy can prevent a decline in lung function
in children with asthma (218). Novel interventions specifically
targeting bronchial hyperresponsiveness need further explo-
ration (219, 220).
KEY POINTS AND RECOMMENDATIONS:
CLINICAL TRIALS
Spirometry
1. Spirometry, as measured by pre-bronchodilator FEV1,
is one of the fundamental objective measures of
asthma control.
2. Pre-bronchodilator FEV1 is a strong independent
predictor of future risk of exacerbations.
3. Spirometry (pre-bronchodilator and post-bronchodi-
lator) should be measured at the baseline examination
of most asthma clinical trials, for all study participants
aged 6 years or more.
4. The relative importance of spirometry among the end-
points in clinical trials depends on the study objectives.
Spirometry provides information on asthma control and
future risk complementary to that obtained from symp-
toms and biomarkers (Tables 1 and 2).
5. FEV1 should be included as a primary endpoint for
studies of bronchodilator therapy. FEV1 is highly
responsive to the successful relief of bronchoconstric-
tion over the entire range of asthma severity, except
for those with normal baseline lung function.
American Thoracic Society Documents
6. Post-bronchodilator FEV1 is recommended in studies
of long-term decline in lung function and airway wall
remodeling.
7. The 2005 ATS/ERS guidelines on performance of
spirometry should be followed. Automated spiro-
meters with test quality checks, and centralized quality
assurance programs, are recommended for use in
clinical trials.
8. FEV1 may be used to characterize the study popula-
tion. This will also facilitate comparisons with pre-
vious studies.
Airway Hyperresponsiveness
1. AHR should be regarded as an integrative disease
marker, reflecting multiple pathophysiologic mecha-
nisms.
2. The 1993 ERS and 1999 ATS standardized methods
should be used. The necessary safety precautions must
be followed at all times.
3. Preference should be given to challenge agents pro-
duced under Good Manufacturing Practice (GMP)
conditions.
4. Where possible, AHR should be included in clinical
trials at baseline to characterize the study population.
5. AHR is a desirable outcome in studies focusing on
modification of underlying disease activity. Direct
challenge agents can be considered for assessing
mid- and long-term disease modification, while in-
direct agents are relatively more responsive when
investigating short-term responses to antiinflamma-
tory interventions.
6. AHR can be used as a predictor of future risk of
exacerbations and decline in lung function in longitu-
dinal studies of childhood and adult asthma.
For Clinical Trials in Primary Care
1. The high standards for quality control and reporting
for spirometry that are recommended in this review
should also apply to studies in primary care.
2. FEV1 is preferable to PEF as a clinic-measured phys-
iologic parameter in asthma clinical trials, although
PEF may have a place in ambulatory monitoring.
3. The current safety recommendations for bronchial
provocation testing preclude its use in most primary
care settings.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL PRACTICE
1. Objective lung function measures should be accurately
performed and recorded in the diagnosis and assessment
of asthma in primary care, but normal lung function does
not exclude a diagnosis of asthma.
2. Lung function measurements in primary care should be
performed on appropriate equipment by trained person-
nel, with monitoring of quality control. Actual values
73
should be entered into the medical record (not just
‘‘normal’’ or ‘‘abnormal’’).
3. Peak flow measurement in primary care for within-patient
comparisons should be performed with the same meter on
each occasion.
4. As outlined in the section on diary measures, peak flow
variability may assist in confirming the diagnosis of
asthma. The upper limit of normal for amplitude percent
mean with twice-daily monitoring is 8%, not the tradi-
tionally quoted cut-point of 15–20%.
5. AHR may be used to guide asthma therapy given the ben-
efits in reducing exacerbations and decline in lung function.
PEDIATRIC ISSUES
1. In children, measuring spirometry is important not only
for assessing asthma control, including acute exacerba-
tions, but also for assessing lung development over
time.
2. Spirometry can be routinely measured in children aged
approximately 6 years and older. However, with appro-
priate training, preschool children may be able to perform
spirometry.
3. Young children have difficulty performing the 6-second
forced expiratory maneuver recommended for spirometry
in adults. Therefore, shorter expiratory times may be
acceptable if reproducible.
4. Forced oscillation procedures and interrupter resistance
(Rint) to measure airways resistance can be applied in
children as young as 3 years of age.
5. Challenge tests for AHR in children with asthma require
satisfactory cooperation with spirometry. Many children
are unwilling to undergo the repeat spirometry required
for challenge testing.
RESEARCH QUESTIONS
Spirometry.
1. The associations between change in lung function and
change in other asthma outcomes (especially dyspnea)
should be explored using the large databases accumulated
from multicenter clinical trials.
2. The relationships between changes in airway structure and
measures of airway function require further investigation.
3. The relative utility of electronic PEF monitoring and
spirometry in the diagnosis and monitoring of asthma in
the community needs to be evaluated more fully.
Airway Hyperresponsiveness.
1. Standardization—the ERS and ATS guidelines for bron-
chial challenge tests require updating, to include GMP
requirements, novel challenge agents, and new aerosol
dosing techniques.
2. Methodology—quicker and simpler methods should be
validated. Is mannitol testing suitable for measuring AHR
in primary care settings?
3. Mechanisms—does AHR assess the potential for airway
narrowing, airway relaxation, or both?
74 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
4. Utility—is an integrative marker such as AHR preferable
to single cell or single molecule biomarkers when moni-
toring disease control? Do the mechanisms of direct and
indirect AHR vary between different asthma phenotypes?
Can this be used for selecting and assessing therapy?
5. Predictive value—is maximal, long-term improvement of
AHR required for optimal asthma control, prevention of
exacerbations, and reduction of the decline in lung
function? Do direct and indirect challenges have similar
predictive value?
6. Is elimination of AHR by novel treatment modalities the
way to cure asthma?
COMPOSITE SCORES FOR ASSESSMENT OF
ASTHMA CONTROL
The concept of composite measures for interval assessments of
asthma control is based on three facts: the generally poor
correlation between different domains of asthma, the absence
of a single ‘‘gold standard’’ for the measurement of asthma
control, and evidence that a composite comprising different
endpoints provides a more complete picture of asthma control
than any single endpoint (158, 221–226). For example, in
a retrospective analysis, Bateman and colleagues showed that
patients who achieved well-controlled asthma according to
a guideline-based composite measure achieved greater
improvements in quality of life than if success in only a single
component of asthma control was achieved (227).
As in other conditions, the selection of endpoints must be
underpinned by knowledge of the clinical manifestations,
pathophysiology and natural history of asthma, and of the
changes that occur with treatment. Although there is not
complete agreement on which parameters should be included
in a composite measure for asthma, there is increasing evidence
supporting their use to evaluate the efficacy of pharmacologic
and nonpharmacologic interventions as well as in clinical
practice (52, 81, 111, 157, 163, 221, 227–229). Evidence relating
to their use in monitoring asthma control in individual patients
is much more limited. This has the potential to be problematic
because, although it is assumed on the basis of group results (26,
230, 231) that each component will trend in the same direction
in response to improving or deteriorating asthma control, this is
not necessarily the case in individual patients or with all
treatments (61). In practice, the clinician might intuitively
weight an individual component measure in making a therapeu-
tic decision. However, weighting has not, in general, been tested
in the use of composite scores in the clinical trial setting. A
situation in which change in a composite score is driven
predominantly by change in only one of its components may
have little clinical validity, either in terms of treatment effect or
in terms of importance to the patient. Thus, interpretation of
composite scores requires that data for their individual compo-
nents should also be reported, and reliance should not be placed
solely on the composite measure (232).
Categorical versus Continuous Measures of Asthma Control
Terms such as ‘‘poorly controlled’’ and ‘‘well-controlled’’ have
been used to describe the overall status of individuals or groups
of patients. However, this leaves a gap or ‘‘no man’s land,’’
where patients are neither poorly controlled nor well controlled.
Individual variables, too, may be couched in positive or
negative terms (e.g., ‘‘asthma control days’’ or ‘‘asthma exacer-
bation days’’). However, loss of control is not the simple
converse of adequate control. Two treatments may be equiva-
2009
lent in terms of well-controlled weeks, but differ significantly
with respect to poorly controlled weeks (16, 33). Some of these
problems can be avoided by expressing control as a continuous
numeric variable, as described below. This approach simplifies
recording and makes self-evaluation by patients possible.
The process of creating such composite scores for asthma has
been problematic because it has been largely empiric. It has
involved transforming several originally continuous variables
that had clinical validity (e.g., symptoms, reliever use) into
individual categories to which scores were assigned, then
summing these scores to create the composite score. Often,
categorical cut-points were then applied to the total score, to
allow categorization of patients into well-controlled, poorly
controlled, and so on. This may facilitate validation of the
composite score against categorical measures such as physician
assessment. However, even when results are expressed as
a continuous numeric variable, there is again an indeterminate
zone between values that provide a high level of certainty that
a patient is not well controlled and those that are considered to
represent adequate control (233) (see Table E1 in the online
supplement). Ideally, the appropriateness of individual cut-
point values for each component should be validated, both
alone and as part of the composite measure to which it
contributes (81, 225).
Group versus Individual Data
Care is required when interpreting the results of composite
measures that are presented as group data. For example, the
proportion of ‘‘asthma control days’’ for a study population may
increase from 21 to 50% (109), but this provides no indication of
the adequacy of control in individuals (221). It is also suscep-
tible to the ‘‘ceiling effect’’ if a large proportion of patients
achieve good control. The proportion of patients that achieve
the target level of control provides a more satisfactory in-
dication of the success of treatment (52, 221).
Time as a Factor in Composite Measures of Control
Like other outcome measures, composite scores which are
derived from daily variables must be indexed to a clinically
meaningful period of time. Existing composite tools use assess-
ment periods varying from 1 week to 1 month (158, 223, 225,
226) (Table E1). To provide a summary of the interval between
infrequent clinic visits, composite scores may be recorded in
a diary. The rate of change also needs to be considered:
different symptoms may not disappear at the same rate. For
example, night waking disappears first as control is achieved,
and is not the first to return when control is lost. This difference
in responsiveness earns night waking a separate place in most
composite measures of control (231).
Composite Measures Expressed as Categorical Variables
Composite measures expressed as categorical variables include
asthma control days, asthma-free days, episode-free days, and
exacerbation-free days. They share certain features: empiric
derivation, lack of standardization, and the limited information
they provide on control in individual patients. However, they
have been widely used in asthma clinical trials.
Asthma control days/asthma-free days/episode-free days. The
simplest composite measures are asthma-free days or asthma-
control days, typically defined as days with no symptoms, no
night-waking, no reliever use, and no exacerbation (221, 222,
234). However, different studies have allowed (235) or excluded
(236) days with pre-exercise b2-agonist use. Some have also
excluded asthma ‘‘attacks’’ and need for additional therapy (24,
108, 234, 237). Some authors have permitted some use of
American Thoracic Society Documents
bronchodilator as reliever without that day losing its asthma-
control status (237). This approach is potentially problematic: it is
arguable that an asthma-free day ought to be one in which reliever
use is zero, even though guidelines do not insist on such a stringent
criterion for well-controlled asthma.
‘‘Well-controlled’’ asthma weeks and ‘‘Total Control’’ weeks.
In many studies, the method for scoring asthma control days has
been lengthened to periods of a week (33, 52, 221) or several
weeks (52, 227), referred to as ‘‘well-controlled weeks’’ or as
a period of ‘‘well-controlled’’ asthma or ‘‘total control’’ (52,
227). Threshold values for each of these outcome variables,
which are usually derived from goals of treatment in asthma
guidelines (8, 9, 238), are mostly arbitrary. Patients are usually
required to achieve control in each outcome and/or for all the
days of the week, for most or all the weeks of the assessment
period (52, 227).
Guideline-based categories of asthma control. Several recent
national and international guidelines have incorporated classi-
fication systems for asthma control, based on clinical consensus.
These have used many different terms; for example, the GINA
Report of 2006 used categories of ‘‘Controlled,’’ ‘‘Partly Con-
trolled,’’ and ‘‘Uncontrolled’’ (8); the NHLBI Expert Panel
Report 3 used ‘‘Well Controlled,’’ ‘‘Not Well Controlled,’’ and
‘‘Very Poorly Controlled’’ (9); the French guidelines used
‘‘Optimal,’’ ‘‘Acceptable,’’ and ‘‘Unacceptable’’ (228); and
a New Zealand report used ‘‘Optimal Control,’’ ‘‘Sub-Optimal
Control,’’ ‘‘Not Well Controlled,’’ and ‘‘Markedly Out of
Control’’ (239). Different criteria and cut-points have also been
used in each of these classification systems.
Composite Measures Expressed as Numeric Variables
The concept of representing control as a numeric score is
attractive and has been adopted by several research groups.
Several measures have been derived. The obvious advantage of
numeric composite measures is that absolute values as well as
changes in numeric scores are relatively easy for patients and
carers to understand and record. With time, patients’ awareness
of the difference between satisfactory versus unsatisfactory
control can be related to the numeric scores. They may be also
more user-friendly for use in programs of self-management (240).
Examples of numeric composite measures are the ACQ
(158), the Asthma Control Test (ACT) (225), the Asthma
Treatment Assessment Questionnaire (ATAQ) (226), and the
Asthma Control Scoring System (ACSS) (223) (Table E1).
Weighting of items has not been examined for any of these
composite scores. Comparisons between such composite scores
are difficult because each uses a different ‘‘gold standard’’ for
what constitutes good asthma control, and they have been
directly compared in only a few studies (241–243).
Before using composite scores, it is important to check
copyright restrictions and charges.
Asthma Control Questionnaire. The ACQ (158) was devel-
oped by Juniper and coworkers for assessing asthma control in
clinical trials and clinical practice. Questions based on recall of
the previous 7 days comprise breathlessness, nocturnal waking,
symptoms on waking, activity limitation, wheeze, frequency of
SABA use, and pre-bronchodilator FEV1% predicted. All
seven items are scored on a 7-point scale without weighting
(0 5 good control, 6 5 poor control) and the overall score
(range, 0–6) is the mean of the responses.
The ACQ has been validated against quality of life and
physician global assessment (81, 111, 158, 163, 233), and the
MID is 0.5 (111). The optimal cut-point for ‘‘Well-Controlled’’
using the Gaining Optimal Asthma Control (GOAL) classifi-
cation is less than or equal to 0.75, and a value of greater than or
75
equal to 1.50 confirms ‘‘not Well-Controlled’’ asthma (233).
Shortened versions, with omission of SABA use and/or FEV1,
perform almost as well as the 7-item version (111, 233) and may
be suitable for self-completion in primary care (224), or in
patients taking LABA. Wording of the validated ACQ is
slightly different from the originally published version (158).
A shortcoming of the ACQ is the observation that most
patients’ scores are less than or equal to 2.5, with scores of
greater than or equal to 4 only occurring with severe exacer-
bations. This suggests that the range and intervals for individual
item scores could be improved. Also, the response scales may be
more complex and time-consuming than is necessary, and its
acceptance for use in primary care needs to be demonstrated.
Although ACQ includes pre-bronchodilator FEV1 (a predictor
of risk of exacerbations), change in this component may be
outweighed by the remaining six symptom/reliever components,
as was seen in one study of LABA monotherapy (61).
Asthma Control Test. The ACT was developed by Nathan
and colleagues (225) and is a trademark of QualityMetric
(Lincoln, RI). This self-completed instrument comprises five
items: shortness of breath, night-time waking, interference with
activity, rescue bronchodilator use, and patient rating of asthma
control, over the past month. Each item is scored using a 1–5
scale and then summed (total score, 5–25). The test is easy to
use, and can be easily completed on the internet (244) or
telephone (245). A pediatric version (C-ACT; range, 0–27) has
been developed for children aged 4 to 11 years (246). It
comprises four questions for the child (how is your asthma
today?; exercise-induced symptoms; cough; and night waking)
with picture prompts for responses, plus three questions for the
parents (days in the last month with daytime asthma symptoms;
wheezing; and night-time wakening because of asthma).
The ACT has been validated against specialist’s rating of
control and spirometry (225, 240, 243), and quality of life (247).
The published cut-points for well-controlled asthma and poorly
controlled asthma are greater than or equal to 20 and less than
or equal to 15, respectively (225, 243, 247); for the C-ACT,
a score of less than 20 corresponds to uncontrolled asthma
(246). A change in ACT score of 1.88 corresponds to a change
of one level in physician rating of asthma control (243).
Although the ACT has been translated into more than 40
languages, further research is required to ensure validity in
different languages and practice settings. The length, presenta-
tion, and ease of use of the ACT make it an attractive option as
a self-assessment tool both in its paper and web-active versions.
Its utility in research requires further assessment.
In a comparative study, ACT and ACQ showed similar
reproducibility, discriminant validity, and sensitivity/specificity
for detecting poorly controlled asthma (243).
Asthma Therapy Assessment Questionnaire. The ATAQ is
a self-administered questionnaire that was developed by
Vollmer and coworkers (226) for assessing asthma control in
patient populations for health utilization and planning purposes
(226, 248, 249) and for clinical use in health maintenance
organizations (250). The ATAQ includes a four-item control
questionnaire (itself often being referred to as ATAQ) and
a longer questionnaire about barriers to asthma management.
The control ‘‘domains,’’ relating to the previous 4 weeks, are:
self-perception of asthma control; missed work, school, or
normal daily activities due to asthma; night-time waking due
to asthma symptoms; and excessive use of ‘‘quick relief’’ inhaled
medication. Answers are dichotomized, leading to a composite
score ranging from 0–4, with 0 representing no control problems
and 4 indicating 4 control problems. Each question has the same
weighting. An ATAQ for children and adolescents (range, 0–7)
has been developed (251).
76 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
The ATAQ has been validated against major quality-of-life
instruments (Medical Outcomes Short-Form 36 [SF-36], St.
George’s Respiratory Questionnaire [SGRQ], and AQLQ)
and has been shown to predict need for acute care for asthma
(248, 252). The questionnaire is very simple to use. Reports of
its use in clinical practice and clinical trials are awaited.
Asthma Control Scoring System. Boulet and colleagues de-
veloped the ACSS with the intention that it should be a simple,
more ‘‘flexible’’ approach to documenting asthma control (223).
The component parts are: clinical (daytime and nocturnal
symptoms, rescue SABA use, and activities, each during the
last 7 d), scored by the patient; physiologic (FEV1); and induced
sputum eosinophil count. It is the only composite instrument to
include a marker of airway inflammation. The overall score is
the average of the available components expressed as a percent-
age, with 100% representing ideal control. However, the
authors proposed that ‘‘the respective weight of each compo-
nent could be interpreted differently by clinicians,’’ opening the
way for different formulae for arriving at a global control score
(253).
A small study examined the ACSS against the Mini-AQLQ
and ACQ in 44 patients with asthma (223), and its measurement
properties were reported from another small study (n 5 44, of
whom 28 had sputum data) (253). It remains to be established in
a larger study whether the systematic or occasional exclusion of
the inflammatory component of the ACSS alters its measure-
ment properties and clinical utility.
Summary
Composite measures are designed to capture different and often
independent aspects of asthma control. They attempt to provide
a summary statement about a complex clinical state. Most of the
current scores focus on current clinical control rather than the
underlying disease activity. Their use in clinical trials enables
numeric comparisons of treatment effects to be made. However,
their interpretation in clinical practice is not necessarily
straightforward, particularly where the response of individual
components may be discordant or some items may be missing.
Considerable progress has been made in validating these instru-
ments for research and clinical use. Whether any improvements
would be achieved by weighting of their individual components
has not been explored, particularly with regard to predicting
future risk.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL TRIALS
1. Composite scores have the potential to be used as
primary or coprimary endpoints in clinical trials.
2. Composite scores should be relatively simple and easy
to administer. They must be suitable for a full range of
patients, and modified to suit different patient groups
(e.g., children).
3. Composite measures that record asthma control as
a simple numeric form should be favored. The number
of individual items in composite measures should be
kept to a minimum, and the contribution of each item to
the performance of the instrument must be evaluated.
4. Existing composite measures have primarily been vali-
dated against physician judgment or other measures of
current clinical control without weighting of their com-
ponents. Against this standard, physiologic data such as
2009
spirometry appear to contribute little in respect of either
responsiveness or precision.
5. Measures that describe achievement of control both
in terms of completeness and duration (e.g., well-
controlled weeks) and measures of departure from
control (e.g., poorly controlled weeks or exacerba-
tions) provide complementary but differing informa-
tion and may be used together. Results for these
outcome measures should be expressed both as group
means and also as the proportion of participants who
achieve the target level of control.
6. Categorical composite measures do not necessarily
provide a full picture of asthma control, particularly
with regard to future risk.
7. Recommendations about composite measures are
limited by the relative lack of validation in a wider
range of settings, over longer periods of follow-up and
in patients with different asthma phenotypes, different
levels of control, and on different types of treatment.
8. Investigators should check conditions of use and charges
before using any of the existing composite scores.
The above statements also apply in clinical trials based in
primary care.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL PRACTICE
A composite measure does not provide full information on
a patient’s current clinical state. Clinical consultations should
continue to include additional questions that address other
aspects of the impact of asthma on the individual.
PEDIATRIC ISSUES
1. Assessment of asthma control in children is usually based
on parent reports. The reliability of symptom assessment
from questionnaires may be influenced by poor symptom
perception and reporting by the child or by the parents.
2. Symptom-free days is a useful endpoint for pediatric asthma
studies, and easier to record than symptom scores.
3. Since the decision to take rescue bronchodilator is often
made by the parents, this indicator may not assess asthma
control accurately in young children.
4. Some age-specific pediatric versions of commonly used
control questionnaires, validated in different languages, are
becoming available for clinical studies (e.g., ATAQ, ACT).
However, their potential application in pediatric clinical
practice needs to be carefully evaluated.
5. In children, the target level of control aimed for is influenced by
safety concerns about the long-term use of high doses of ICS in
this age group. In this context, a careful assessment of risk and
benefits may lead to acceptance of less than complete symp-
tomatic control of asthma.
RESEARCH QUESTIONS
1. The measurement properties of composite measures
should be validated both in clinical trials (groups of
American Thoracic Society Documents
patients) and in large prospective studies in ‘‘real life’’
settings (individuals) including in primary care, to ensure
that they provide content validity as well as reflect
clinically meaningful outcomes.
2. Further studies are required to establish whether pro-
spective monitoring of asthma control using composite
measures improves asthma outcomes and/or predicts
future risk, and whether adding physiologic or inflamma-
tory components to composite scores adds value in
particular phenotypes, for example in poor perceivers or
patients with severe asthma.
3. There is a need for further studies to investigate the most
useful composite measures for primary care settings.
BIOMARKERS OF AIRWAY INFLAMMATION
Over the last 15 years there has been increasing interest in the
noninvasive assessment of airway inflammation as an adjunct to
the assessment of clinical asthma control (254–256). A number
of candidate measures have been developed and validated (254,
257–259). Some have been evaluated in clinical trials, and there
is increasing evidence that the information provided by non-
invasive markers results in more effective use of available
asthma treatments (260–262).
The assessment of airway inflammation is moving rapidly,
but not all new techniques have been developed to the point
where their clinical utility has been validated. We have selec-
tively focused on the methodological aspects of induced sputum
analysis, measurement of the fraction of exhaled nitric oxide
(FENO), exhaled breath condensate (EBC) analysis, and the use
of serum eosinophilic cationic protein (ECP). Indirect assess-
ment of airway inflammation using the peripheral blood eosin-
ophil count has a long pedigree and showed promise in earlier
studies (168, 263). However, there has been little recent work
on this marker and it will not be considered further.
Induced Sputum
Measurement methods and interpretation. The methodology for
sputum induction and processing was reviewed by an ERS
Task Force in 2002 (264). Induced sputum is not possible in
children aged less than 8 years. Most centers report success
rates, defined as obtaining a readable sputum cytospin, of 80 to
90% in adults, and somewhat lower in children (265). Low
baseline lung function (FEV1 , 1.0 L) is a relative contrain-
dication, and in all patients, pretreatment with SABA is
recommended to avoid inducing bronchospasm. Occasionally,
patients experience excessive coughing culminating in vomit-
ing during sputum induction.
The protocols for sputum induction differ mainly in the
output of the ultrasonic nebulizer used, and sputum processing
(sputum plugs or whole sample selection). Usually sputum is
induced with nebulized hypertonic saline and processed with
the aid of the mucolytic dithiothreitol. There is no evidence that
different methods result in clinically important differences in
success rates or sputum differential cell counts (264, 266).
The principal readout from induced sputum is the differential
inflammatory cell count, expressed as a percentage, based on
a manual count of 400 inflammatory cells (eosinophils, neutro-
phils, macrophages, lymphocytes, and epithelial cells) on a stained
cytospin preparation. The total cell count, cell viability and
squamous cell contamination should also be reported (264).
Inflammatory cell counts can also be expressed as total count
77
(i.e., total cell count 3 proportion of that inflammatory cell).
There is an approximately linear relationship between the
differential and total count up to a differential count of 80%.
Above this level, total counts may provide more information on
the intensity of the inflammatory response; however, they are less
repeatable than differential counts (254, 255). This may be
particularly important when assessing neutrophilic inflammation.
The induced sputum supernatant can be used to assay
molecular markers of inflammation. In general, this technique
is more successful for effector mediators than cytokines, and for
Th-1–associated cytokines compared with those associated with
Th-2 responses (264). Assay of sputum supernatant mediators
has made an important contribution to our understanding of the
mechanisms of airway disease, but there is no evidence that
these measures inform our understanding of asthma control.
They will not be considered further.
Normal ranges and reproducibility. Three community-based
studies have assessed induced sputum inflammatory cell counts
in normal subjects, producing very similar estimates of normal
ranges, with the upper limit of normal for sputum eosinophil
differential count being 1.9% (Table E2) (267–269). One study
(269), which assessed a wider age range than the other two,
reported an increase in the sputum neutrophil count with
increasing age, particularly over the age of 50. An age effect
has also been seen in patients with asthma, and an age
correction factor has been suggested (270). In normal control
subjects, differential counts of each cell type have an approxi-
mately normal distribution. In patients with asthma, the sputum
differential eosinophil count tends to be right-skewed. Log-
transformation normalizes the data adequately, although it is
usually necessary to add 0.2 to all counts to remove zero values.
An alternative approach is to use nonparametric tests. The
same applies to sputum total cell counts.
There have been several estimates of within-subject re-
producibility of induced sputum inflammatory cell counts
(Table E2) (255, 271, 272). A reasonable estimate of the
between- and within-subject standard deviation (in log 10
units) of the sputum differential eosinophil count in asthma
is 0.75 and 0.4, respectively. Intraclass correlation coefficients
of 0.79 to 0.99 for eosinophils and 0.82 to 0.99 for neutrophils
have been reported for replicated differential counts from
different laboratories.
Induced sputum facilities are currently only available in
secondary care and specialist laboratories, and this situation is
likely to remain. The cost of sputum induction and processing is
largely made up of technician time.
Responsiveness. In asthma, the sputum differential eosino-
phil count is consistently reduced (two- to sevenfold) by
corticosteroids (273, 274) and is increased (up to sevenfold)
by allergen challenge (275, 276), before asthma exacerbations
(261), and after prednisone reduction (277). The dose–response
curve for ICS plateaus at a low dose, and there is little evidence
of an additional effect above 200 mg/day (beclomethasone
equivalent) in most patients (278, 279). The time scale for the
reduction in sputum eosinophil counts with ICS has not been
adequately addressed, but an effect may be seen as early as
6 hours (280, 281). There is a consensus view that a halving or
doubling of the sputum differential eosinophil count is clinically
significant (264); a change in sputum eosinophil count of this
magnitude has a sensitivity of 90% for loss of asthma control
after ICS withdrawal (282). There are no consistent reports of
interventions that modify the differential count of inflammatory
cells other than eosinophils.
Relationship between sputum measures and other clinical
measures. Eosinophilic airway inflammation, defined as a spu-
tum eosinophil count outside the normal range (i.e., . 1.9%), is
78 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
seen in different clinical contexts. One meta-analysis/review
estimated that an abnormal count is present in 66 to 100% of
patients with asthma and up to 40% of patients with isolated
chronic cough (283). There is consistent and compelling evi-
dence that the sputum eosinophil count is related to a beneficial
short- and long-term response to corticosteroid therapy irre-
spective of the clinical context (273, 284–286). An induced
sputum eosinophil count of less than 3% has a negative pre-
dictive value of 100% for a greater than 12% increase in FEV1
in response to ICS (287). There is accumulating evidence of an
important degree of dissociation between eosinophilic airway
inflammation and symptoms/disordered airway function in some
asthma phenotypes (3, 4, 260, 288).
Corticosteroid reduction studies have consistently shown that
a raised sputum eosinophil count is predictive of the development
of an exacerbation (212, 277, 282, 289), and management
strategies aimed at normalizing sputum eosinophil counts have
been associated with up to 60% reduction in severe asthma
exacerbations (260, 261, 290), with particular benefit in patients
taking LABA or those with more severe asthma (261). In this
population, induced sputum analysis has been shown to be cost
effective (260). Although the majority of patients in primary care
demonstrate concordance between symptoms and eosinophilic
airway inflammation, significant discordance is seen in patients
referred for secondary care (288). Cluster analysis has demon-
strated that with sputum-guided therapy, the majority of benefit
in reducing exacerbations occurs in patients with inflammation-
predominant asthma, whereas the majority of benefit in reducing
ICS dose is seen in patients with predominant symptoms and
little inflammation (288). The differential neutrophil count has
been shown to relate inversely to the post-bronchodilator FEV1
in a variety of clinical settings (270, 291).
Fractional Concentration of Exhaled Nitric Oxide
The exact relationship between the fractional concentration of
exhaled nitric oxide (FENO) and the underlying pathologic
process in asthma remains unclear (292). The increasing use
of FENO as a surrogate marker for the presence of clinically
relevant eosinophilia is based on significant correlations be-
tween FENO measurements and eosinophilic airway inflamma-
tion (293), although the scope for both false positives and false
negatives remains significant (294).
Measurement methods and interpretation. This subject has
been reviewed by several Task Forces (257, 295, 296). There is
now a consensus that FENO is best measured before spirometric
maneuvers, at an exhaled rate of 50 ml/second maintained within
10% for more than 6 seconds, and with an oral pressure of 5 to
20 cm H2O to ensure velum closure. Results are expressed as the
NO concentration in ppb (equivalent to nanoliters/liter) based
on the mean of two or three values within 10% (297).
NO output can be calculated as the product of the exhaled
NO concentration in nanoliters per liter and the exhalation flow
in liters per minute. Alveolar NO concentration can be esti-
mated from measurement of NO output at multiple exhalation
flows (298). Alveolar NO may reflect distal lung inflammation;
it is increased in patients with severe asthma and in one study it
was reduced by oral, but not inhaled, corticosteroids (299). The
clinical role of this derived measurement has not been firmly
established.
Normal ranges and reproducibility. Using the above methods,
robust measurements of FENO are available in children (300)
and adults (297, 301). A number of studies have reported
‘‘normal values’’ (301–304). FENO is often higher in atopic
subjects (305) and lower in current smokers (306). Passive
smoking causes only a transient (z 30 min) reduction in FENO
2009
(307, 308). In healthy children aged 17 years or less, higher
levels of FENO were reported with increasing age (300). In one
study, higher FENO with increasing age was also observed in
adults (309) but the majority of studies have not confirmed this.
There is a broad consensus regarding the effects of sex; most but
not all studies indicate that FENO is 20 to 30% higher in males
than in females (302, 303, 310–312). In females, levels may also
be influenced by the menstrual cycle (313).
The use of reference values may be helpful when using FENO
as a diagnostic test; in this setting, sex, smoking status, and
atopy should be taken into account. A reasonable estimate of
the normal range for FENO in healthy adults is less than 35 ppb;
this is reduced to less than 25 ppb when outliers are removed
from the analysis and to less than 20 ppb when outliers and
atopics are removed (297, 300). In corticosteroid-naı̈ve patients
presenting with nonspecific respiratory symptoms, high FENO
levels (. 50 ppb) are associated with a significant clinical
response to ICS independent of the final diagnosis (314). For
patients with diagnosed asthma, it seems unlikely that reference
values will have a role in assessing what is a ‘‘normal’’ FENO. In
people with asthma, even when clinically stable, FENO values
are generally higher than in healthy control subjects (63, 292).
In practice, comparisons for individual patients are best made
against serial measurements obtained when the patient is
clinically stable.
FENO values approximate to a log normal distribution in
healthy control subjects and subjects with asthma. Between-
subject standard deviation is approximately 10 ppb in normal
control subjects and 25 ppb in subjects with asthma (297).
Within-subject standard deviation is approximately 1.6 to 2 ppb
(297, 300). Reproducibility of log-transformed data is not
available.
Measurement of FENO requires expensive equipment and it
is currently only available in specialist laboratories, although
cheaper portable FENO analyzers are now becoming available.
There is some concern that absolute values may differ between
different analyzers, which has obvious implications for normal
ranges (315, 316), and stability over time needs to be estab-
lished. The between-center variability in FENO is likely to be
similar to the within-subject variation if the same type of
analyzer is used.
Responsiveness. FENO is increased (by about 60%) during
the late response to allergen in subjects with atopic asthma
(317), and is reduced two- to fourfold by corticosteroids in
patients with asthma (279, 318, 319). There is conflicting
information on the dose–response relationship between ICS
dose and reduction in FENO. Available data are consistent with
a dose-related effect with low dose treatment but no additional
benefit at a group level above a budesonide dose of 400 mg/day
(279, 320, 321). The time scale of response to ICS has not been
adequately addressed; estimates for the time to a measurable
effect range from 3 days (321) to 8 weeks (318). Based on the
available data, an estimate of the clinically meaningful change
would be twofold in either direction.
Associations with other outcome variables. FENO is a reason-
ably robust estimate of the presence of eosinophilic airway
inflammation across a wide range of patients differing in diag-
nosis (294). The association is lost in current smokers (294).
There is accumulating evidence of an important degree of
dissociation between eosinophilic airway inflammation and
symptoms/disordered airway function in patients with asthma
(3, 4, 260, 288), so FENO is likely to provide information about
eosinophilic disease that is not available otherwise.
In asthma, one corticosteroid reduction study has shown that
a raised FENO is predictive of loss of asthma control (63), but
two others were less convincing (212, 282). In two further
American Thoracic Society Documents
pediatric studies, FENO predicted the need for continuing ICS
therapy in patients whose asthma appeared stable: after ICS
withdrawal, increasing FENO predicted loss of control (322, 323),
whereas persistently low FENO predicted successful ICS with-
drawal (323). Michils and coworkers reported that in patients
with mild asthma, a decrease in FENO of greater than 40% had
a positive predictive value for improved ACQ of 83% (324).
Five studies have investigated asthma outcomes when ICS dose
was guided by FENO (262, 325–328). In one study, this approach
resulted in lower ICS doses compared with standard clinical
management (262). A study in children showed that a manage-
ment strategy based on FENO was associated with improved
AHR (325). All three studies reported fewer exacerbations
when treatment was guided by FENO, but the results were not
statistically significant (262, 325, 326). Individually, the out-
comes of these studies may be due to problems with study
design or power, but overall the conclusion is that optimizing
ICS dose is not a primary indication for using FENO in un-
complicated asthma.
Exhaled Breath Condensate
Methods and interpretation. The collection of EBC and sub-
sequent analysis of inflammatory markers is a more recent
development in noninvasive asthma monitoring technologies.
Cooling of expired air condenses exhaled breath, which contains
water vapor, respiratory droplets, and particles. This is collected
and assessed using conventional assays. Methodologic aspects of
EBC collection and analysis have been reviewed by an ERS
working party (258). Current methods for the collection of EBC
vary primarily in the type of condenser. The physical surface
properties of each condenser system may influence the conden-
sate that is collected, and it is possible that there may be great
variation in particles collected by each system. The influence of
salivary contamination on EBC values may be considerable, as
many of the mediators assayed are found in high concentration
in saliva (329).
Many markers of airway inflammation have been reported in
EBC. The most commonly reported markers include those that
indicate oxidative stress such as 8-isoprostane and hydrogen
peroxide, as well as the leukotrienes (cysteinyl and B4) and
airway pH. Other less frequently reported markers include
cytokines such as IL-6. The measurement characteristics of
the common markers are shown in Table E3. The application of
non–hypothesis-driven ‘‘metabolomics’’ may assist in clarifying
the relationship between EBC and other markers of asthma
control (330).
Serum Eosinophil Cationic Protein
Methods and interpretation. A standardized collection, process-
ing, and testing method has been described for ECP (331).
Critical factors include storage temperature and the time to
analysis. Serum ECP concentrations are higher than ethyl-
enediaminetetraacetic acid plasma concentrations, probably
because blood eosinophils continue to produce ECP ex vivo in
the absence of additives. Serum ECP concentrations are pre-
ferred, as they appear to be better at discriminating health from
disease (331). Circadian variation of serum ECP concentrations
is present, indicating the need to standardize collection time
(332), and there is evidence that a promoter polymorphism is
a major determinant of serum ECP levels (333). Normal values
vary between populations, and there is conflicting information
on the effect of smoking, atopy, and age (334–336). With
repeated measurements, the within-subject standard deviation
in log units is 0.161.
79
Serum ECP increases with allergen exposure or after labo-
ratory allergen challenge and decreases after allergen avoidance
and ICS therapy, although it may be less responsive than
sputum eosinophil count or FENO (337, 338). However, com-
pared with eosinophil counts, ECP measurements in either
induced sputum (339) or serum (339, 340) fail to reflect
treatment-related changes in chronic asthma, suggesting that
serum ECP is not a sensitive or reliable means of evaluating
eosinophilic airway inflammation. Moreover, serum ECP does
not appear to predict a response to corticosteroid therapy (341).
Finally, a randomized trial comparing a serum ECP-based
algorithm for managing asthma with a conventional algorithm
found no improvement in symptom scores, in spite of increased
doses of ICS (342).
KEY POINTS AND RECOMMENDATIONS: BIOMARKERS
IN CLINICAL TRIALS
The role of biomarkers in asthma includes defining the
phenotype at baseline, assessing underlying disease activity
on treatment, and predicting the risk of future events.
Induced Sputum
1. Sputum induction is feasible and safe, and the
techniques of sputum induction and processing have
been well validated, although some technical exper-
tise is required.
2. Assessment of eosinophilic airway inflammation using
induced sputum provides additional, clinically impor-
tant information about ICS responsiveness and pre-
ventable future risk of exacerbations.
3. Minimization of eosinophilic airway inflammation
should be considered as an additional criterion for
control of the underlying disease activity and for
reduction of future risk, especially in patients with
more severe asthma. Eosinophilic airway inflamma-
tion should be assessed, where possible, in clinical
trials involving this population.
FENO
1. FENO measurements provide easily obtained informa-
tion on underlying disease activity where it is charac-
terized by eosinophilic airway inflammation, but the
positive and negative predictive values for eosino-
philia are suboptimal.
2. FENO does not provide information about other types
of airway inflammation, and this may be a problem in
more severe asthma, where neutrophilic inflammation
may be more important.
3. The clinical utility of FENO-based management strat-
egies has not been explored extensively. Currently
available evidence suggests a role in identifying the
phenotype in airways disease, particularly in the
identification of corticosteroid responsiveness.
4. Due to logistic and cost issues, FENO is the only bio-
marker likely to have a role in primary care–based
asthma studies, although it is possible that with tech-
nological improvements, other techniques including
sputum induction could have a role in the medium term.
80 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
KEY POINTS AND RECOMMENDATIONS:
CLINICAL PRACTICE
1. Where possible, biomarkers should be employed to pro-
vide information about underlying airway inflammation,
a domain of the asthma ‘‘syndrome’’ that would not
otherwise be available to the clinician.
2. Induced sputum analysis provides information on the
pathology of asthma that aids decision making both as
to diagnosis and treatment. The use of induced sputum to
augment the clinical assessment of patients with moderate
to severe asthma has been shown to be cost efficient in
a specialist setting.
3. FENO measurements may be used as a surrogate marker
for eosinophilic airway inflammation. They may be used
to evaluate the potential for response to corticosteroid
treatment.
4. Low values of FENO (, 25 ppb in adults, , 20 ppb in
children) may be of particular value in aiding decisions
about reducing corticosteroid dose, or alternatively for
determining that ongoing airway symptoms are unlikely
to be due to eosinophilic airway inflammation.
PEDIATRIC ISSUES
1. Experience with biomarkers in childhood asthma is
limited, but biomarkers could prove to be useful in
making an asthma diagnosis and for selecting appropriate
medications based on phenotype.
2. FENO is a prototype for the application of biomarkers in
children with asthma, and may be helpful in decisions on
starting and stopping ICS, and perhaps monitoring med-
ication effects.
3. Reliable measurement of FENO using the recommended
single-breath online technique is limited to children 5
years and older.
4. Successful sputum induction in children is limited to those
children 8 years and older, in whom success rates are around
60 to 70% in academic settings. Serial assessment of sputum
may be problematic, as many children are unwilling to
undergo repeat sputum inductions during follow-up visits.
RESEARCH QUESTIONS
1. More research is needed to establish whether sputum
processing and analysis can be simplified to enable wider
use in clinical trials.
2. More information is needed on the utility and effective-
ness of sputum eosinophil-directed management in less
severe asthma.
3. Information on what constitutes a clinically relevant
change in sputum neutrophils is required.
4. More information is required on the utility of FENO
measurement as a tool for monitoring asthma control.
5. There is a need for translational research to clarify the
relationship between biomarkers and other parameters of
asthma control, to establish the optimal frequency of
monitoring, and to confirm the clinical and cost effective-
ness of biomarker measurements in primary care and
other settings.
2009
6. More work is needed on the validation of the various
measures from EBC, and to describe the relationship be-
tween these measures and other markers of asthma control.
The application of non–hypothesis-driven ‘‘metabolomics’’
may assist in this process. Studies to address whether using
EBC results in improved clinical decision-making or better
asthma outcomes are required.
INDIRECT MEASURES OF ASTHMA CONTROL
Loss of asthma control potentially leads to unscheduled use of
health care, loss of work and school productivity, and need for
additional medication. Unscheduled use of health care may
range from primary care consultations through to hospitaliza-
tion or admission to an intensive therapy unit. Such episodes
have significant implications for individuals and health care
providers, and constitute a significant health economic burden.
Measures of health care utilization provide surrogate measures
for asthma control, which are particularly useful when direct
clinical measures are not available, for example, at a population
level. The most extreme indirect measure of poor asthma
control and exacerbations is mortality, but this is more suited
as an endpoint in the analysis of administrative datasets (e.g.,
from health maintenance organizations) than for clinical trials.
Establishing the cause of death is often difficult, particularly in
elderly patients.
Most existing studies have failed to define any standard
methodology of reporting and there are limited data available
regarding the reproducibility, responsiveness, or associations of
these outcome measures.
The report and recommendations on indirect measures of
asthma control are divided into four sections: (1) primary care
consultations; (2) urgent health care, hospitalizations, and ER
visits; (3) corticosteroid tablet usage; and (4) health economic
outcomes.
Levels of Health Care
In reporting health care usage as an indirect measure of asthma
control, it is important to define usage clearly, particularly for
economic evaluations. This involves recognition of the fact that
health care systems in different countries often define and
structure primary and secondary care provision in different
ways. Primary health care (i.e., initial or basic care, to which
patients have direct access) may be provided by a generalist,
a specialist, or a trained nurse practitioner (343). The concept of
‘‘specialists’’ differs between health care systems. In many
European countries, for example, the specialist works in
secondary care and the family doctor/general practitioner works
in primary care. In other countries, specialists may work in
community-based facilities but not in hospitals. In the present
document, ‘‘primary care’’ is used to refer to clinic-based con-
sultations to which the patient has direct access, and ‘‘secondary
care’’ refers to visits to a hospital, ER, or equivalent facility (i.e.,
the classification is based on the facility at which care is
provided, not the training of the health care professional).
Primary Care Consultations
Primary care consultations have been reported as an outcome
measure for asthma control. There is no current standard meth-
odology or recommendation for primary care consultations.
Ways in which the variable has been reported in the past include:
d All primary care asthma-related consultations per unit
time (344–347)
American Thoracic Society Documents
d Unscheduled or emergency asthma-related primary care
consultations per unit time (348–353)
Some primary care consultations reflect optimal asthma man-
agement, not just for repeat prescriptions, but with evidence
favoring structured proactive review at regular intervals over
opportunistic or unscheduled review (354, 355). The ideal
frequency of review for each patient depends on his/her disease
severity and control. Hence, in publications, there is a need to
distinguish between routine scheduled care consultations (or
routine study visits) and unscheduled consultations, with only
the latter acting as a marker of poor asthma control.
Sometimes, consultations have been subdivided according to
the type of health care provider, the mode of consultation, or
who initiated the consultation:
d Primary care physician face-to-face contact (345, 347, 356,
357)
d Primary care nurse (or other health care provider) face-to-
face contacts (349, 358, 359)
d Telephone advice (360)
d Home visits (348)
d Doctor/practice-initiated ‘‘routine’’ consultations (361)
d Patient-initiated consultations (348, 349, 353, 361, 362)
Nurse-led care and telephone consultations, while common in
some countries, would be unknown in other countries. Home
visits because of asthma are becoming infrequent in all health
care systems, and probably do not need to be reported separately.
With considerable variation in routine documentation pro-
cedures between practices, even within the same country, it is
often difficult to separate planned or scheduled consultations
from those that are unplanned, unscheduled, or truly emergency
consultations. The definition of what constitutes an unscheduled
or emergency consultation is often not specified in publications,
and may range from administrative definitions (e.g., request for
an appointment within 24 h) to clinical definitions (e.g.,
consultation judged as being needed for worsening asthma).
There may be differences between the patient’s and clinician’s
opinion about the reason for a consultation, especially for
patients with concurrent conditions (363). It is recommended
that where possible a clinical definition should be used (i.e., an
unscheduled patient-initiated contact with a health care pro-
fessional resulting from worsening asthma symptoms). If this
definition cannot be used, the reasons should be explained, and
the alternative definition justified.
Some studies have reported the number/percentage of patients
requiring an unscheduled asthma appointment over a time span
(e.g., 1 yr), and others, the number of consultations. It is important
to distinguish between a single prolonged episode of poor control/
exacerbation and multiple episodes. Where accurate information
on the frequency and date of unscheduled consultations exists, this
way of presenting data will give complementary information to
the total/mean/median number of consultations in the studied
populations, and both should be reported.
Source of data about unscheduled consultations. Different
studies have used different ways to collect primary care
consultation data; these include ‘‘unscheduled visit’’ trial pro
forma completed at the time of consultation by the physician,
retrospective questionnaires filled in by patients (41, 350, 364)
or by physicians (361), and written or electronic clinical or
administrative databases (344, 345, 365, 366). The results from
different sources may not be identical, particularly as responses
by patients are usually based on their recollections rather than
on contemporaneous notes (363).
81
In order of desirability and reliability, the following methods
of data collection about unscheduled care can be used for
clinical trials (references are examples):
1. Standardized physician-completed data collection forms,
recording symptoms, physiologic measurements, and ther-
apy changes at the time of patient contact. This is the
recommended method to provide the most robust in-
formation. If this method is not used, the reason should be
explained and justified.
2. Subject-completed data collection forms, completed near
to the time of contact (< 3 mo) (27)
3. Retrospective physician-completed data collection forms
(361)
4. Retrospective subject-completed data collection forms.
Data should be verified or corroborated from other
sources if possible.
5. Inspection of routinely collected medical or administra-
tive records (344, 345, 366, 367). This method is appro-
priate for pragmatic trials and observational research.
In clinical trial reports, the type, source, and definitions of visit
data should be described (e.g., in an online supplement).
Unscheduled Use of Secondary Health Care
Good asthma control should normally be associated with no
unscheduled need for secondary health care (i.e., in a hospital,
ER, or equivalent facility). Because of its high cost, secondary
health care has major implications for health economic out-
comes. However, studies focusing on secondary health care in
asthma require large sample sizes and a long duration, hence it is
often not feasible to use this variable as the primary endpoint.
Reported rates of secondary health care utilization have
varied, and are clearly more frequent in populations with more
severe asthma. In studies of mild-moderate asthma, secondary
health care visits ranged from 0.2 to 0.5/patient/year (32, 48, 246,
368–370), with higher levels (0.86/patient/year) in more severe
asthma (371). It should be stated whether ER visits that result in
a hospitalization are distinct from the total count of ER visits.
However, the threshold for attendance in the ER or for
admission to hospital will vary from country to country, reflect-
ing global differences in the practice of medicine. Although
many individual ER attendances for asthma will represent
severe asthma exacerbations, as reflected by the need for
systemic corticosteroids, some may represent attendances for
‘‘sick care.’’ There is value in recording secondary health care
attendances as an overall marker of health care utilization for
poor asthma control, particularly when the study focus is at
a population or community level.
The recommended method of reporting results is the number
of events per patient per year, expressed as the weighted mean.
Data should be reported separately for ER visits, hospital-
izations, and intensive care unit admissions. It is recommended
that visits that occur 7 days or less from another visit should be
considered to be part of the same episode. The absolute
magnitude of changes in secondary health care utilization is
generally small, as the events occur infrequently. Conversion of
the rate to number of events per 100 patient-years may in-
appropriately give the perception of large changes (368).
Recording of data for unscheduled use of secondary health
care is relatively easy. Since the events are infrequent, data can
be collected by patient report, and/or administrative records
(363). If there is a code for asthma in the first or second listed
82 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
diagnosis, it is highly likely that the admission was at least
partly, if not mostly, related to asthma.
Systemic Corticosteroid Usage
Worsening asthma control or exacerbations may require the use
of additional or emergency medication. In clinical practice, this
may involve several agents including bronchodilators, but the
present comments are restricted to systemic corticosteroid
usage (usually tablets for adults, but also including intravenous
or intramuscular usage and liquid preparations in young chil-
dren) as an indirect measure of asthma control.
Use of systemic corticosteroids includes both maintenance
treatment in patients with severe asthma, and short courses used
in the management of poor asthma control or exacerbations.
Corticosteroids may be initiated either by investigators, using
protocolized criteria or clinical discretion, or by patients using
physician-prescribed self-management plans. There is no cur-
rent standard method of reporting systemic corticosteroid usage
and no documented ‘‘normal’’ range. In a small minority of
patients with severe asthma, corticosteroid tablets may be used
on a regular basis in day-to-day treatment. More commonly,
corticosteroid tablets are given in short courses to treat wors-
ening asthma. Regular corticosteroid tablet usage may there-
fore reflect asthma severity (a need for the regular use of
corticosteroid tablets to achieve symptom control and normal
lung function, i.e., ‘‘difficult to treat’’ asthma [6]), whereas the
frequency with which courses of corticosteroids are needed is
a marker of control. The Task Force Working Group on
exacerbations has specified 3 days or more of systemic cortico-
steroid use as a mandatory criterion for severe exacerbations, so
data for systemic corticosteroid use will closely parallel data for
severe exacerbations, but will also include early cessation by
patients of a longer prescribed course (372) or patient self-
administration for shorter periods of time.
The way in which short-term use of systemic corticosteroids
has been recorded in clinical trial reports is far from uniform.
Some reports have recorded the number of patients needing
oral or systemic corticosteroids as a marker of loss of control
(373) and others have used a need for systemic corticosteroids
to define a serious asthma-related attack without quantifying
severity in any other way (41, 364, 375). Of the studies which
were reviewed, many were too short to report systemic corti-
costeroid use as an outcome (365, 366). When reported,
systemic corticosteroid use was most commonly expressed as
mean number of courses per unit time, usually per year (27),
with some studies also reporting the percentage of patients
needing a course of corticosteroids (367), or days with cortico-
steroid tablets due to exacerbations (32).
One potential problem with reporting systemic corticoste-
roids relates to the lack of quantification of corticosteroid
dosage. The most accurate measurement of corticosteroid use
would be to report the milligrams of prednisolone taken per
patient per unit time. However, trial reports do not always make
it clear whether the corticosteroid dose was standardized in the
protocol or left to physician discretion, and the duration of
a course is rarely mentioned, nor is the handling of closely
consecutive courses described. Daily corticosteroid dose would
also be difficult to calculate if some patients were on regular
maintenance therapy, where it would need to be recorded as
extra milligrams of prednisolone per patient per unit time.
Accordingly, in the absence of definite evidence that the
quantity of corticosteroid taken is a better marker of control than
the need for any corticosteroid, it is recommended that the total
number of courses of corticosteroids per patient per year should
be recorded, but that all studies should record whether courses
2009
were standardized or left to individual physician’s discretion. In
those taking maintenance oral corticosteroids, a ‘‘course’’ is
defined as a short-term increase in dose with a subsequent
reduction to the baseline level. Further study of the relationship
between corticosteroid bursts and hospitalization is needed.
Health Economic Data
In general, loss of asthma control and exacerbations lead to
higher medical and nonmedical costs and lower quality of life. A
full and detailed accounting of quantifiable costs is required to
reflect the economic impact of poor control and of therapeutic
interventions. Health economic data are frequently collected to
support local or national coverage and reimbursement of
interventions. They comprise data about the direct cost of
medical resource utilization (e.g., health care contacts, hospital
use, and medications) as well as data about indirect costs,
established from patient-reported data concerning loss of
work/school time and quality of life. Data regarding school or
work absence has been used as an endpoint in some studies
(usually of an educational rather than a pharmacologic in-
tervention), but it is likely to be a poor reflection of control.
The Work Productivity Assessment Instrument (WPAI) has
been developed and validated as a tool for characterizing the
degree of absence and productivity impairment in asthma for
health economics and burden estimation, but the WPAI is only
useful for characterization, not for outcome evaluation. Reilly
and colleagues (375) were the first to report validity and
reproducibility of the WPAI; more recently, the WPAI has
been used as a measure of disease burden in asthma (376).
Resource utilization data from clinical and observational
studies are used to create aggregated patient-level profiles of
health care utilization. It is important to identify the dates of
service so that unique episodes of care (which may include
several health care visits) can be constructed. Utilization data
are then combined with local and relevant health care unit price
data to give an estimate of health care costs. Unit price data
should not be collected as part of a clinical trial protocol.
Rather, a separate and parallel protocol should be established
for the purpose of ascertaining nationally representative (or
jurisdiction-specific) price information.
Typically, health care cost data are reported in terms of
weighted mean or median costs per patient per year. The main
findings from economic evaluations should be reported in local
currency, as this is more relevant to local decision makers. In
addition, a more global currency (USD, EURO) can be pro-
vided, particularly for multinational studies or for publications
in international journals.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL TRIALS
1. Primary care consultations should be expressed as the
weighted mean or median rate per patient per year,
divided into scheduled and unscheduled consultations.
Only unscheduled consultations serve as a marker of
poor asthma control; these should be defined as those
initiated by the patient because of worsening asthma.
Data should be collected, where possible, from stan-
dardized physician-completed forms at the time of
patient contact. Telephone consultations and nurse
consultations should be reported separately.
2. Unscheduled use of secondary health care is most useful
as an outcome measure in populations in which such
American Thoracic Society Documents
events are likely to be common (i.e., moderate-severe
asthma). For adequate sampling, studies should be of at
least 6 months’ duration. Rates should be recorded as
mean number of ED attendances for asthma, mean
number of admissions to hospital for asthma, and mean
number of admissions to intensive care unit for asthma,
each expressed as weighted mean per patient per year.
3. Systemic corticosteroid usage (by tablets, suspension,
or injection) is an outcome marker of control and
should be recorded as the total number of courses per
patient per year, expressed as the weighted mean.
In those taking maintenance oral corticosteroids a
‘‘course’’ is defined as a short-term increase in dose
with a subsequent reduction to the previous level.
Information should be provided about whether dura-
tion/doses of corticosteroid courses were standardized
or according to physician discretion.
4. Health economic data. A full and detailed accounting
of medical and nonmedical costs, including work and
school loss, is required to reflect the economic impact
of poor asthma control for use in health economic
studies. Data on national or jurisdictional prices for
medical care and pharmaceutical services are required
to produce estimates of cost. To be representative,
unit price data should be collected outside any clinical
trial protocol.
The above statements are also relevant to clinical trials
conducted in primary care.
SUMMARY FOR CLINICAL PRACTICE
1. Primary care consultations should be recorded during the
visit as scheduled or unscheduled, based on a clinical as-
sessment, and further classified by mode (office visits,
home visits, telephone consultations etc.). The record
should state who saw the patient (doctor, nurse, educator,
etc.)
2. All hospital referrals of patients with asthma, and the
outcome, should be recorded. Follow-up arrangements
should be documented so that the patient can be recalled
to see the primary care doctor if necessary.
3. All prescriptions for systemic corticosteroids for asthma
exacerbations should be recorded. Patients prescribed
these medications in reserve (for later use with self-
management plans) should be provided with means to
record when and why they have used the medications.
4. Copies of medical certificates issued for absence from
work due to asthma should be recorded in the notes.
PEDIATRIC ISSUES
1. Estimating unscheduled health care consultations for
asthma in children is complicated by consultations for
infection-related nonspecific airway symptoms.
2. Antibiotics and short courses of high-dose ICS are
frequently, though often inappropriately, prescribed for
asthma exacerbations in children. They should be consid-
ered when monitoring respiratory events possibly related
to asthma, especially in young children.
83
3. Assessment of nonmedical costs of poor asthma control
should consider not only the child’s absence from school, but
also loss of parental work-related productivity.
4. Determination of health care utilization and nonmedical
costs in pediatric and adolescent clinical trials is best
based on reports by parents or caregivers rather than
patients.
RESEARCH QUESTIONS
1. How and why patients and physicians decide to use/
increase systemic corticosteroids is unclear, and how such
use is recorded varies. Further work is needed to clarify
whether any objective measures predict need/increase of
corticosteroids and whether a more detailed recording
(for example mg prednisolone/patient/unit time) enhan-
ces understanding or quantification of control.
2. As regards time off school, and consequent parental costs,
more work is needed to clarify what influences need for
school absence, which may not always reflect loss of
asthma control alone (i.e., it may also be influenced by
other socioeconomic factors).
3. More work is needed to understand how health economic
evaluations can take into account the existing variation in
delivery between different countries or regions.
HEALTH-RELATED QUALITY OF LIFE (HRQOL)
For over a decade, generic or asthma-specific quality-of-life
questionnaires have been included in clinical trials to assess
treatment benefits as perceived by the patient. They have been
used because (1) some treatment effects can be only identified
by the patient, (2) patients provide a unique global perspective
on treatment effectiveness, and (3) standardized assessment
may be more reliable than informal interview.
Quality of life has been defined as ‘‘the functional effects of
an illness and its consequent therapy upon a patient, as perceived
by the patient’’ (377). It includes somatic sensation (the problems
associated with symptoms), physical and occupational function,
emotional and psychological impact, and social interaction.
Factors contributing to a sense of well-being include good health,
a secure social and occupational environment, financial security,
spirituality, self confidence, and strong, supportive family rela-
tionships. Health-related quality of life can be considered as the
component related to the overall burden of a chronic disease with
respect to these domains. It is important to use specifically
designed tools to assess health-related quality of life (HRQOL),
and to differentiate the information that they provide about
treatment response from other subjective beliefs and clinical
outcomes.
Why Measure HRQOL in Asthma?
Most studies using generic or disease-specific instruments have
reported that asthma affects HRQOL (378, 379), with lower
quality-of-life scores being found in patients with more severe
asthma (380). However, clinical trials in asthma have often
focused on outcomes that are primarily of importance to the
clinician, such as symptom scores or lung function. These do not
necessarily reflect all the characteristics of the disease. For
example, there are no data reporting the relationship between
inflammatory markers and HRQOL. The patient’s perception
of the burden of disease may be completely different from the
clinician’s, and may vary according to the patient’s circum-
stances and life expectations. Measuring HRQOL can add
84 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
valuable information to better assess the impact of poor asthma
control and/or its severity (i.e., difficulty to treat [6]). Initially,
HRQOL questionnaires were not intended to be used as
endpoints in clinical trials, but many studies now include an
assessment of HRQOL in the assessment of effects of therapy,
both pharmacologic (52, 381, 382) or nonpharmacologic (383),
to assess the global benefit to patients.
Interpretation of HRQOL Results
The application of HRQOL questionnaires is far from estab-
lished in clinical practice, and there are no clear guidelines for
their use in the assessment of asthma control. HRQOL data
should be interpreted with caution, as the performance charac-
teristics of an instrument (score, validity, reproducibility, and
responsiveness) may vary from the original description and
purpose according to the context of the study. For most of the
asthma-specific quality of life questionnaires, an estimation has
been made of the MID, the smallest difference in score that
patients perceive as beneficial and that, in the absence of
troublesome side effects and excessive cost, would mandate
a change in a patient’s management (384–387). Importantly,
MID for quality of life has often been assessed from the
investigator’s perspective, but is now primarily anchored to
the patient’s perspective, on the basis of the idea that that only
the patient is in a position to judge whether a difference is
important.
Choice of HRQOL Questionnaires
It is a difficult task to select the best HRQOL tool to be used in
a clinical routine setting or in a clinical trial. One should select
the most adequate, easy to use, best validated, and responsive
questionnaires. Use of some questionnaires is subject to copy-
right restrictions and charges. The ATS website provides
a comprehensive list of English-language generic and asthma-
specific HRQOL tools for adults and children (388). Several
well-validated HRQOL tools are described below and in Table
E4. All were developed using broadly similar methodologies
and have a similar general structure and content. There are two
types of quality of life questionnaires: generic and specific.
Generic HRQOL Questionnaires
Generic HRQOL questionnaires such as the SF-36 (389, 390)
were designed for use by patients with any chronic illness,
and they include items such as tiredness, headache, or gastric
problems. Their utility is questionable in the context of asthma.
The real advantage of these instruments is to compare the
burden of different chronic conditions (e.g., asthma and arthri-
tis). By covering a wide spectrum of symptoms and activities,
they are too superficial to reflect the reality of a patient’s life
with asthma, and they should be complemented by a more
specific tool. Generic instruments are limited by their inability
to identify specific problems in individual patients and their lack
of responsiveness to small but potentially important changes in
quality of life. These views have been challenged and at least
one study showed that the SF-36 instrument was able to detect
changes in asthma ‘‘severity’’ as well as treatment effects (391,
392). Generic health-related QOL instruments have also been
developed and validated for children of various ages (393, 394).
Measurement methods and content. In adults, the most
commonly used and the best-validated generic HRQOL tool
is the SF-36 (389, 390). It includes 36 items measuring three
major health attributes and nine health concepts. It is self-
administered and can be completed in 10 minutes. This tool has
been validated and found to be reliable, with translations
available in many languages.
2009
Reference values, reproducibility, and responsiveness. Scoring
of the SF-36 is complex, and yields eight scale scores ranging
between 0 and 100. A high score is consistent with a positive
health status. The SF-36 has good internal consistency and
cross-sectional validity in patients with asthma (391).
Comparison with other disease-related outcomes. Many stud-
ies have reported low to moderate relationships between airflow
limitation (measured by FEV1), respiratory symptoms, and
HRQOL. In one cross-sectional study of patients with a broad
range of asthma severity, rho for correlations between FEV1
and SF-36 scales ranged from 0.09 for mental health to 0.40 for
physical functioning (395).
Specific Asthma-related QOL questionnaires
Currently, there are several validated asthma-related quality of
life questionnaires. These instruments include the functional
impairments (physical, emotional, social, and occupational) that
are most important to patients with asthma. They have been
reported to be much more sensitive to change in patients’ quality
of life than generic health profiles. Questionnaires with sub-
stantial validation data are summarized below, and more detail is
provided in Table E4.
AQLQJuniper. The standardized version of the AQLQJuniper is
a 32-item, disease-specific questionnaire that is reported as
having strong measurement properties and validity for measure-
ments of functional impairment in adults with asthma (396,
397). Patients score their experiences during the last 2 weeks on
a 7-point scale (1 5 severe impairment to 7 5 no impairment).
The overall AQLQ score and mean responses for different
domains (symptoms, activities, emotions, and environment) are
calculated. The MID is reported to be 0.5 points (383). The
AQLQJuniper has proved responsive in before-after studies and
in clinical trials (382, 398, 399). Construct validity has been
assessed using both conventional measures of asthma severity
and generic quality of life instruments. The AQLQJuniper has
been shown to correlate with asthma control questionnaires
such as ACQ (158) and ATAQ (226). There is a poor correla-
tion between change in AQLQJuniper and change in FEV1 (399).
For pediatric studies, Juniper and colleagues have also
validated the Pediatric Asthma QOL Questionnaire (PAQLQ)
(400) and the Pediatric Asthma Caregivers QOL Questionnaire
(PACQLQ) (401).
Mini-AQLQ. This questionnaire is a short version of the
AQLQJuniper, and includes five items on symptoms, four items
on activity limitations, three on emotional function, and three
concerning environmental stimuli, scored with the same 7-point
scale as the AQLQ (402). Measurement properties of the Mini-
AQLQ are good, but not as strong as the original AQLQ.
AQLQMarks. This is a 20-item self-administered question-
naire (403, 404) that provides a total score together with
subscale scores for breathlessness, mood disturbance, social
disruption, and concerns for health, calculated by averaging of
item scores. Lower scores indicate better quality of life.
Validation studies showed good short-term test-retest repro-
ducibility. The questionnaire was internally consistent in a sam-
ple of outpatients and in a community sample with asthma.
Weak correlations in the expected direction were seen with
three markers of asthma severity (spirometry, AHR, and
number of asthma medications) (403).
The validity and responsiveness of AQLQMarks were
assessed in 44 adults with asthma (404). Change in AQLQ score
was significantly correlated with change in symptom score and
change in AHR, with only a trend for change in peak flow
variability and in Sickness Impact Profile score. The AQLQMarks
was capable of detecting differences between improved and
stable subjects (P 5 0.007).
American Thoracic Society Documents
Adams and colleagues modified the AQLQMarks to a 22-item
questionnaire using a 7-point Likert response scale (MAQLQ-M)
(406), inverted so that higher values represented better quality of
life. Adult subjects with moderate-severe asthma were evaluated
at baseline and 3-month follow-up. In cross-sectional and
longitudinal analysis, stronger associations were seen with
symptom and self-rating scales than with lung function,
medication usage, or health service utilization measures.
Higher baseline scores were associated with lower risks over
12 months for hospital admissions and repeated ER visits.
The Living with Asthma Questionnaire (LWAQ). The LWAQ
(407) has 68 items covering 11 domains of asthma experience,
which were derived from focus group discussions. The scale
compensates for acquisition bias as well as allowing a ‘‘not
applicable’’ response category. Validity of the scale was dem-
onstrated by confirmation of expected group differences, and
the retest reproducibility was 0.948. A shorter version of the
LWAQ has been published (389).
The St. George’s Respiratory Questionnaire. The SGRQ (408)
is a 76-item self-completed questionnaire that was developed
for assessment of quality of life in COPD. It is widely used in
COPD clinical trials (409), but has also been validated and used
in asthma (408, 410, 411).
The Asthma Questionnaire-20 (AQ20). The AQ20 (412) was
developed as a short and simple measure of health status in
asthma, using 20 dichotomous responses (yes/no) relating to the
effects of asthma on the patient’s life, emotions, and activities.
The reproducibility of the AQ20 is high (413). The AQ20 score
correlates with AQLQJuniper (r 5 20.40, P , 0.001) and with
SGRQ (r 5 0.46, P , 0.0001) (414).
Role of HRQOL Assessment in Drug Evaluation Process
At present, the role of HRQOL assessment in clinical trials is
linked to the willingness of the study sponsor to incorporate
such measures into the process of drug development. Regula-
tory agencies such as EMEA and FDA have shown interest in
patient-reported outcomes and specifically in HRQOL, and the
FDA has provided draft guidelines to facilitate the development
of robust questionnaires and to better understand the informa-
tion obtained from HRQOL.
Several large-scale clinical asthma trials have incorporated
the AQLQJuniper as a measure of the global impact of asthma
control (13, 415, 416). In the Formoterol and Corticosteroids
Establishing Therapy (FACET) study, the correlation in in-
dividual patients between changes in clinical indices and
changes in AQLQ score during the 12-month randomized
period were weak to moderate (maximum r 5 0.51) (13).
In conclusion, HRQOL questionnaires measure the impact
of asthma on the individual, and provide complementary rather
than direct information about asthma control or severity.
Several HRQOL instruments have been developed and vali-
dated, with an estimate of an MID in HRQOL score provided
for some of these. Further work is needed to determine the
specific role of HRQOL measures in clinical trials and drug
development.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL TRIALS
1. HRQOL is a patient-reported outcome that repre-
sents the overall impact of the level of asthma control
and exacerbations on quality of life. It should be used
as a specific assessment tool in asthma clinical trials.
85
2. To correctly interpret changes in HRQOL, the MID
should be defined for each validated HRQOL
measure.
3. Potential gains in HRQOL resulting from treatment
may be offset by the impact of drug-related side-
effects or co-morbidities.
4. The effect of cultural and educational differences on
HRQOL assessment should be considered in the
development and use of questionnaires.
5. Generic health-related QOL instruments have been
validated and may be used to compare the impact of
asthma with that of other chronic illnesses.
6. Copyright and conditions of use should be checked
before quality of life questionnaires are used in
clinical trials.
Each of these points is also applicable for clinical trials in
primary care.
KEY POINTS AND RECOMMENDATIONS:
CLINICAL PRACTICE
1. Even if formal HRQOL scores are not recorded in clinical
practice, clinicians should endeavor to evaluate quality-
of-life issues relating to asthma from the perspective of
the patient.
2. Assessment of HRQOL provides a way to investigate the
unmet needs of a patient, and can facilitate negotiation of
further objectives in the management of the patient’s
asthma.
PEDIATRIC ISSUES
1. All disease-specific quality-of-life instruments used for
pediatric studies should be validated for relevant age
groups.
2. The Pediatric Asthma Quality of Life Questionnaire
(PAQLQ) is a pediatric disease-specific QOL instru-
ment designed and validated in several languages for
children aged 6 to 18 years. An asthma-related QOL
questionnaire for caregivers has been developed by the
same authors.
3. For any pediatric QOL instrument, the study protocol
should specify whether the carer or the child should
answer the QOL measure.
4. Child-completed QOL questionnaires must take into
consideration the child’s reading level. Children under
12 years of age may have difficulty reading or under-
standing a questionnaire without assistance.
5. When children are assisted by their parent in completing
a questionnaire, their responses change. Therefore, child-
completed questionnaires should either be completed by
the child alone or with the assistance of professional
staff—as specified in the protocol for that test.
RESEARCH QUESTIONS
1. The comparative usefulness of validated disease-specific
HRQOL questionnaires and composite asthma control
scores or other asthma-related outcomes should be eval-
uated in clinical trials and clinical practice.
86 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180 2009

2. The time-course of change in HRQOL, and the numbers
of required assessments, should be better defined. Long-
term trials are recommended due to the potential of
exacerbations to affect HRQOL in asthma.
3. The relationship between HRQOL and future risk of
adverse events should be examined, as HRQOL may be
influenced by factors that drive health-related behavior
such as medication adherence.
4. The positioning of HRQOL questionnaires within the
approval process for new therapeutic interventions by
regulatory bodies should be further evaluated.
5. There is a need for clinical trials to assess whether the use
of formal HRQOL tools in routine clinical care leads to
better outcomes.
SUMMARY AND OVERALL RECOMMENDATIONS
The recommendations of the Task Force are based on the
development of a model, published elsewhere (6), that links the
concepts of asthma phenotypes, underlying disease activity,
asthma severity, and asthma control. ‘‘Asthma control’’ is defined
as the extent to which the manifestations of asthma have been
reduced or removed by treatment. It should be assessed not only
by current clinical features such as symptoms, reliever use, and
lung function, but also by evaluation of the patient’s risk of
adverse outcomes (e.g., exacerbations or medication side-effects)
in the future. ‘‘Asthma severity’’ is now defined as the intensity of
treatment required to achieve good asthma control; for severe
asthma, there is a requirement for (not necessarily just pre-
scription or use of) high-intensity treatment, and mild asthma can
be well controlled with low-intensity treatment. Asthma severity
may be influenced by the underlying disease activity, and by the
patient’s phenotype, both of which may be further described
using pathologic and physiologic markers. These markers may
also act as surrogate measures for future risk. Biomarkers provide
a link between phenotype, severity, and control (6).
Rationale and List of Measures
Tables 1 and 2 provide the overall recommendations from the
Task Force for therapeutic studies which focus on the impact of
an intervention on asthma control. Table 1 provides the
rationale for the selection of outcome measures, and Table 2
lists the individual measures together with their relative impor-
tance (essential, desirable, or optional). As described in METH-
ODOLOGY, the Task Force recommendations are based on the
definitions of asthma and asthma control, the dual emphasis on
optimizing current control and minimizing future risk, and the
measurement properties and feasibility of each measure.
The recommendations in Tables 1 and 2 primarily relate to
clinical trials in adults and adolescents. For clinical trials in
children aged 6 to 12 years, some special considerations apply

TABLE 1. RECOMMENDED OUTCOME MEASURES RELATING TO ASTHMA CONTROL FOR CLINICAL TRIALS: RATIONALE
Definitions Method of Observation Purpose of Recording the Outcome Measures

1. Baseline characteristics d Characteristics of the study
population before randomization
2. Outcome measures for the assessment of treatment effect . . ..
. . .on current clinical d Current clinical asthma control
control is the extent to which the clinical
manifestations of asthma (symptoms,
reliever use, airway obstruction)
have been reduced or removed
by treatment
d Direct measurement at baseline
d Baseline 5 randomization visit or
(for diary measures) the final 2 wk
of run-in
d Direct measurement of level of
current clinical asthma
control throughout the study†
d On each occasion, level of control
should be assessed
over the previous 1-4 wk
d To describe the patients’ pretreatment
level of asthma control
d To characterize the study population
in terms of asthma phenotype(s) and
underlying disease activity
d To record baseline levels of predictors*
of future risk
d To assess the effect of the treatment on
level of clinical control
d To describe the range of responses to
study treatment
d To identify discrepancies between current
clinical control and markers of underlying
disease activity, e.g., with masking by
LABA monotherapy or in poor perceivers

. . .on future risk
d Future risk refers to the risk of
adverse outcomes such as
exacerbations, poor asthma control
or accelerated decline in lung
function, or side-effects of treatment,
in the near or distant future
d Direct measurement, e.g., number
of exacerbations, or decline in
post-BD FEV1, during a long-term
study†
d Indirect assessment based on
probability—the extent to which
the treatment leads to improvement
from baseline in predictors* of future
risk (surrogate measures).
d To assess the effect of the treatment
in reducing the occurrence of those adverse
outcomes which can be directly measured
in the study, e.g., in a long-term clinical trial,
the number of exacerbations in the treatment
and control groups can be directly recorded
d To predict the effect of the treatment in
reducing those adverse outcomes which
are not able to be quantified in this
particular study (e.g., because the study
is too short or it is not powered for major
adverse outcomes), by recording the effect of
the treatment on predictors of future risk.*

Definition of abbreviations: BD 5 bronchodilator; LABA 5 long-acting b2-agonist.

* ‘‘Predictors’’ are modifiable factors that have been observed to be associated with increased risk of adverse asthma outcomes in the future (such as exacerbations,
future poor asthma control, and accelerated decline in lung function, or side effects of treatment), and that can be used as surrogate measures in studies in which the
adverse outcomes cannot be directly measured. An example of a predictor is FENO, which has been observed to be associated with an increased risk of exacerbations.
†
In general, it is preferable to record the level of asthma control throughout the study rather than just at the end of the treatment period. Use of data from the whole
treatment period will reflect the magnitude and rate of treatment response, the extent of variation in level of control, and the occurrence of exacerbations, all of which
are relevant to the overall impact of treatment on the patient. This will typically include assessment at each study visit, or, for diary measures, over multiple periods each
of 1–4 wk. The resulting multiple data points for each patient can be analyzed by mixed model (or equivalent) analyses, which are to be preferred over merely averaging
the data over the whole treatment period.
American Thoracic Society Documents 87

TABLE 2. RECOMMENDED OUTCOME MEASURES RELATING TO ASTHMA CONTROL FOR CLINICAL TRIALS: LIST OF MEASURES
1. Baseline characteristics*
2. Outcome measures for the assessment of treatment effect . . ..
. . .on current clinical
control
Minimum Set of Measures (Essential) Desirable Optional
†
Symptom-free days
d d Symptom/reliever/lung function diary** d On-treatment FEV1kk
Reliever use†
d d Airway hyperresponsiveness††
‡
d Pre-BD FEV1 d Biomarkers‡‡
d Post-BD FEV1
x d Treatment side-effectsxx
d Composite scores
{ d History of exacerbations
d Quality of life
k (OCS, ER visits, hospitalizations){{
†
d Symptom-free days d On-treatment FEV1kk d Biomarkers‡‡
†
d Reliever use d Symptom/reliever/lung function d Airway
d Composite scores
{ diary** hyperresponsiveness††
d Exacerbation (within last d Indirect measures, e.g., corticosteroid d Post-BD FEV1x
1-4 wk)*** use, health care utilization
d Quality of life
k

. . .on future risk
For direct measurement of adverse For direct measurement of adverse
outcomes: outcomes
d Exacerbations*** d Symptom/reliever/lung function diary**
x
d Post-BD FEV1 (for assessment of lung d Health care utilization (e.g., corticosteroid

function decline) use, ER visits, hospitalizations); mortality

d Composite scores
{ due to asthma
d Treatment side-effects
xx For indirect assessment of risk of adverse
For indirect assessment of risk of adverse outcomes
††
outcomes d Airway hyperresponsiveness (as predictor
‡
d Pre-BD FEV1 (as predictor for of future risk)
‡‡
exacerbations) d Biomarkers (as predictor of future risk)

Definition of abbreviations: BD 5 bronchodilator; ER 5 emergency room; OCS 5 oral corticosteroids.

* Baseline characteristics are assessed at the randomization visit, or, for diary measures, during the final 2 wk of run-in.
†
Symptom-free days and b2-agonist use (reliever-free days and occasions/day) may be ascertained from a diary or from a visit-based questionnaire (or from suitably-
worded components of a composite score). If a visit-based questionnaire or composite score is used, the period of assessment for reliever use and symptom-free days
should be no more than 4 wk. Symptom-free days are not suitable as an outcome measure for study populations with very frequent or very infrequent symptoms.
‡
Pre-BD FEV1 is defined as FEV1 recorded after appropriate withholding of short-acting and long-acting bronchodilator, if used.
x
Post-BD FEV1 is defined as FEV1 recorded 15 min after administration of 400 mg of albuterol or equivalent. It is not considered necessary to specify whether long-
acting b2-agonist or study medication should be withheld, as FEV1 would be considered to be close to plateau levels after 400 mg albuterol.
{
Composite scores: at least one, and preferably two, validated composite measures (e.g., ACQ, ATAQ, ACT) should be recorded. Check with the copyright holder for
conditions of use.
k
Quality of life is not in itself a measure of clinical asthma control. Quality of life is a measure of the impact of the level of asthma control on the patient’s well being.
Check with the copyright holder for conditions of use.
** Diary measures should be obtained from validated diary questions and, where possible, using electronic data collection to improve data quality and avoid data
fabrication. Morning PEF is the most consistently reported lung function variable from diaries.
††
Airway hyperresponsiveness is a marker of underlying disease activity, and the extent to which this has been modified by treatment. It allows assessment of
discrepancies with the observed level of clinical control (e.g., with masking by LABA monotherapy). In the assessment of treatment effect, airway hyperresponsiveness
also serves as a predictor of future risk (see footnote to previous table).
‡‡
Biomarkers (e.g., sputum eosinophils, sputum neutrophils, exhaled nitric oxide) are markers of underlying disease activity, and the extent to which this has been
modified by treatment. They allow assessment of discrepancies with the observed level of clinical control (e.g., with masking by LABA monotherapy). In the assessment
of treatment effect, some biomarkers also serve as predictors or surrogate measures of future risk. The storing of DNA may offer the opportunity to study gene–
environment interactions that affect future risk. The approach should comply with local ethical guidelines.
xx
Treatment side effects: record side effects relevant to study medication(s), as-needed medications, or exacerbation medications, and any withdrawals due to adverse
events. Note that some side effects related to asthma medications (e.g., dysphonia [ICS] or mood changes [OCS]) may not be perceived by patients as ‘‘health
problems’’ and therefore may be underestimated by routine Adverse Event questioning.
{{
In most cases, the history of previous exacerbations cannot be directly compared with prospectively recorded exacerbations because of recall errors, but is
important for characterizing patients at entry.
kk
‘‘On-treatment FEV1’’ is defined as FEV1 recorded without withholding of study medication. To standardize the measurement, it should be performed 6 hours after
SABA where possible. ‘‘On-treatment FEV1’’ is only substantially different from ‘‘Pre-BD FEV1’’ for studies in which subjects are taking LABA. In such studies, preference
should be given to recording ‘‘Pre-BD FEV1’’ (where LABA is withheld) because of the additional information that this measure provides about future risk.
*** Severe exacerbations have been defined by the Task Force as events requiring systemic corticosteroids for > 3 d and/or a hospitalization/emergency room visit for
asthma requiring systemic corticosteroids.

(e.g., ambulatory lung function monitoring is not generally
appropriate in this age group). Details are given in the pediatric
‘‘boxes’’ within this document.
The principles described above also apply for the assessment
of asthma control in clinical practice. Specific recommendations
for clinical practice are found at the end of each of the sections
of this document.
Choice of Endpoints
Some therapeutic interventions principally affect clinical con-
trol, others target future risks, and others (e.g., disease modi-
fiers) may impact both. Likewise, some measures provide
information about current clinical control, some about future
risk, and some about both. Hence, it is not appropriate to
recommend a single endpoint for the assessment of asthma
control. This is reflected in Tables 1 and 2.
In long-term therapeutic studies, the effect of the intervention
on some future risks (e.g., exacerbations), may be measured
directly. However, it is impractical for all studies to be of
sufficient duration to directly measure these events, so, in shorter
studies, inferences about some future risks may be drawn from
measurement of biomarkers and physiologic measures.
From Table 2, it is recommended that all clinical trials that
aim to study the effect of an intervention on asthma control
should include and report the ‘‘minimum’’ or ‘‘essential’’ out-
88 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
come measures for both current clinical control and future risk.
Each study report should refer to the extent to which both of
these goals of treatment have been met. If it is not possible in
a particular clinical trial to include any measures relevant to
‘‘future risk,’’ this limitation of the study design, and the
implications for the conclusions from the study, should be
acknowledged.
For some trials, the nature of the study hypothesis may
mandate additional or alternative outcome measures. These
include trials that are primarily intended to investigate the
effect of treatment on the underlying disease process or those
intended to evaluate specific pharmacologic effects. The choice
of the primary endpoint in any individual study may vary
according to the specific intervention.
Care should be taken in the interpretation of existing studies
or guidelines that refer to asthma control, severity, and exacer-
bations, as the concepts underpinning the analysis or recom-
mendations may be different from the new definitions estab-
lished by the Task Force (6).
Future Directions
The present Task Force has provided a redefinition of the
concepts of asthma control and severity (6), so that the rationale
behind the assessment of asthma may be improved. The new
definitions provide a framework for recommendations regard-
ing the optimum assessment of asthma control in clinical trials.
However, these are not the final answers, and the overall
landscape may yet change. Further progress will result from
integrated studies that variously combine the clinical, physio-
logic, and/or pathologic measures which, when used to guide
treatment, are found to lead to the best outcomes for patients.
Single outcome measures may not suffice for assessment of
treatment response in the context of the current multi-compo-
nent definition of asthma. The existing composite asthma
control scores are a first step toward developing measurement
tools that will integrate information about current clinical
control and future risk, to reflect both the benefits and potential
harm of treatment. Such tools need to be simple enough for use
in clinical practice as well as in clinical trials. Extending this
approach to include bioinformatics-style techniques in large
datasets will identify the best combination and weighting of
factors, recorded at baseline or during the early course of
treatment, that predict a patient’s subsequent course. For
example, in a recent study by Osborne and coworkers (66),
the final models predicting need for acute care were very
different from current composite clinical scores.
Emerging work on biomarkers suggests that several meas-
ures of airway inflammation should be evaluated in a similar
way for inclusion in composite control scores. Cluster analysis
has identified clinical phenotypes that are characterized by
discordance between symptoms and airway inflammation, and
that predict response to sputum-guided treatment (288). In
relatively asymptomatic chronic diseases such as hypertension
and diabetes, treatment decisions are based on biomarkers
rather than on symptoms (417), but their use is not without
criticism. However, biomarkers may ultimately prove to be
more appropriate in asthma, particularly for some phenotypes.
This approach is already accepted in asthma for patients with
poor perception of airway obstruction (73). The possibility
needs to be envisaged that, in the future, a well-validated
biomarker might override symptoms as the basis for treatment
decisions: while not ignoring the burden of symptoms to
patients, we ought not to be locked in to the definitions of
asthma control provided in this document, or the current
stepwise approach to treatment.
2009
This Statement was prepared by a Task Force of the Assembly on
Allergy, Immunology, and Inflammation of the American Tho-
racic Society and the Inflammatory Airway Diseases and Clinical
Allergy Assembly of the European Respiratory Society.
The members of the Task Force were:
ERIC D. BATEMAN, M.B., Ch.B., M.D., FRCP, DCH, University of
Cape Town Lung Institute, Cape Town, South Africa
LOUIS-PHILIPPE BOULET, M.D., FRCPC, FCCP, Institut de Cardiologie
et de Pneumologie de l’Hôpital Laval, Québec, PQ, Canada
HOMER A. BOUSHEY, M.D., University of California, San Francisco,
CA
WILLIAM W. BUSSE, M.D., University of Wisconsin, Madison, WI
THOMAS B. CASALE, M.D., Creighton University, Omaha, NE
PASCAL CHANEZ, M.D., Ph.D., Université de la Méditerranée,
Marseille, France
PAUL L. ENRIGHT, M.D., University of Arizona, Tucson, AZ
PETER G. GIBSON, M.B., B.S., Centre for Asthma & Respiratory
Disease and Hunter Medical Research Institute, University of
Newcastle, Australia
JOHAN C. DE JONGSTE, M.D., Ph.D., Sophia Children’s Hospital,
Rotterdam, The Netherlands
HUIB A. M. KERSTJENS, M.D., Ph.D., University Medical Center,
Groningen, The Netherlands
STEPHEN C. LAZARUS, M.D., University of California, San Francisco,
CA
MARK L. LEVY, M.B., Ch.B., FRCGP, University of Edinburgh,
Edinburgh, UK
PAUL M. O’BYRNE, M.B., FRCP(C), Firestone Institute for Re-
spiratory Health, McMaster University, Hamilton, ON, Canada
MARTYN R. PARTRIDGE, M.D., FRCP, Imperial College, London, UK
IAN D. PAVORD, D.M., FRCP, University of Leicester, Leicester, UK
HELEN K. REDDEL, M.B., B.S., Ph.D., FRACP (co-chair), Woolcock
Institute of Medical Research, Camperdown, Australia
MALCOLM R. SEARS, M.B., Ch.B., FRACP, FRCPC, Firestone In-
stitute for Respiratory Health, McMaster University, Hamilton,
ON, Canada
PETER J. STERK, M.D., Ph.D., University of Amsterdam, Amster-
dam, The Netherlands
STUART W. STOLOFF, M.D., University of Nevada School of
Medicine, Reno, NV
STANLEY J. SZEFLER, M.D., National Jewish Medical and Research
Center and University of Colorado Health Sciences Center,
Denver, CO
SEAN D. SULLIVAN, B.S.Pharm., M.Sc., Ph.D., University of Wash-
ington, Seattle, WA
D. ROBIN TAYLOR, M.D., MRCP (UK), FRCPC (co-chair), Dunedin
School of Medicine, University of Otago, Dunedin, New
Zealand
MIKE D. THOMAS, M.B., B.S., FRCP (Lond), University of Aber-
deen, Aberdeen, UK
SALLY E. WENZEL, M.D., University of Pittsburgh, Pittsburgh, PA
Observers:
EUGENE J. SULLIVAN, M.D., FCCP (FDA)
BADRUL A. CHOWDHURY, M.D., Ph.D. (FDA)
DAVID J. LYONS, M.D., M.Sc., FRCPI, MRCP (EMEA)
The members of the Task Force Working Groups were:
Exacerbations: Paul M. O’Byrne, Thomas B. Casale, Mark L.
Levy, Helen K. Reddel, Stanley J. Szefler
Diary Data: Johan C. de Jongste, Huib A. M. Kerstjens, Stephen
C. Lazarus, Helen K. Reddel
Lung Function and Airway Hyperresponsiveness: Paul L. Enright,
Homer A. Boushey, Peter J. Sterk
Composite Scores: Eric D. Bateman, Malcolm R. Sears, Helen K.
Reddel, D. Robin Taylor
Biomarkers: Ian D. Pavord, Peter G. Gibson, D. Robin Taylor
Indirect Measures: Martyn R. Partridge, Sally E. Wenzel, Sean D.
Sullivan, Mike D. Thomas
American Thoracic Society Documents
Health-Related Quality of Life: Pascal Chanez, William W. Busse,
Stuart W. Stoloff, Louis-Philippe Boulet
Pediatrics: Stanley J. Szefler, Johan C. de Jongste
Primary Care: Mark L. Levy, Stuart W. Stoloff, Mike D. Thomas
Conflict of Interest Statement: The following conflict of interest statements relate
to the 3 years to November 2008. H.K.R. has received consultancy payments
from GlaxoSmithKline (GSK) and AstraZeneca (AZ), has served on advisory
boards for GSK and AZ, and has received lecture fees from AZ. H.K.R.’s employer
has received funding from AZ, GSK, Boehringer Ingelheim (BI), Novartis, and
Pharmaxis. D.R.T. has received lecture fees from AZ and Aerocrine AB; and an
industry-sponsored grant from Aerocrine AB, Solna, Sweden. E.D.B. has served
on advisory boards for Almirall, AZ, BI, GSK, Merck, Nycomed, Pfizer, and Sanofi-
Aventis; has received lecture fees from AZ, BI, GSK, Nycomed, and Pfizer; and has
received industry-sponsored grants from Almirall, AZ, BI, GSK, Merck, Nycomed,
Pfizer, and Sanofi-Aventis. L.-P.B. has served on advisory boards for AZ, Altana,
GSK, Merck Frosst, and Novartis; has received lecture fees from 3M, Altana, AZ,
GSK, Merck Frosst, and Novartis; and has received industry-sponsored grants
from AZ, GSK, Merck Frosst, Schering, BI, AsthmaTx, Ception, Topigen, and
Alexion. H.A.B. has served on advisory boards for GSK; has received lecture fees
from Genentech, Novartis, and BI; has provided consultancy services for
Theravance and Nanomix; and has received an industry-sponsored grant from
GSK. W.W.B. has provided consultancy services for Genetech/Novartis, Isis, GSK,
Altanta, Wyeth, Pfizer, Dynavax, Centocor, Johnson & Johnson, CV Therapeutics,
Hoffman-LaRoche, Ception, Amgen, Alza, Takeda, Millenium, MAP Pharmaceut-
icals, Merck, Asthmatic, AZ, MedImmune, Memory Pharmaceuticals, Altair, PDL
BioPharma, Schering Corporation, TEVA, and Abbott Laboratories; has received
lecture fees from Novartis, Merck, AZ, and GSK; and has received industry-
sponsored grants from Novartis, Dynavax, Wyeth, Centocor, GSK, Medicinova,
Pfizer, Dey, Astellas, Inflazyme, Ception Therapeutics, and Biowa. T.B.C. has
provided consultancy services for Novartis, Genentech, OSI Pharmaceuticals,
Zymo/Genetics; has served on advisory boards for Novartis, Genentech, Allux,
and Capnia; has received lecture fees from Merck; has received industry-
sponsored grants from Dynavax, Novartis, NIH/NHLBI, Alcon Research, Allergy
Therapeutics, Curalogic, Amgen, Allied Research, Genentech, Novartis, Pfizer,
Schering, and Capnia. P.C. has provided consultancy services for Almirall, BI,
Centocor, GSK, AZ, Novartis, Teva, Chiesi, and Schering Plough; has served on
advisory boards for Almirall, BI, Centocor, GSK, AZ, Novartis, Teva, Chiesi, and
Schering Plough; has received lecture fees from Almirall, BI, Centocor, GSK, AZ,
Novartis, Teva, Chiesi, Schering Plough; and has received industry-sponsored
grants from Almirall, BI, Centocor, GSK, AZ, Novartis, Teva, Chiesi, and Schering
Plough. P.L.E. has provided consultancy services for Pfizer and InterMune. P.G.G.
has received lecture fees from AZ, GSK, and Novartis; has received industry-
sponsored grants from Pharmaxis and GSK; and has patents pending with CRC
for Asthma, University of Newcastle. J.C.d.J. has served on advisory boards for
GSK, and has received industry-sponsored grants from Aerocrine, GSK, Roche,
AZ, Chiron, Transave, Pfizer, and Friesland Nutrition. H.A.M.K. has served on
advisory boards for GSK, AZ, BI, and Nycomed. H.A.M.K.’s employer has received
research and travel funding from AZ, GSK, BI, Novartis, Nycomed, and
Pharmaxis. S.C.L. has no financial relationship with any commercial entity that
has an interest in the subject matters discussed in this project. M.L.L. has
provided consultancy services for Ranbaxy, Met Office, and SCOPUS; has served
on advisory boards for Trinity Cheisi, Meda Pharmaceuticals, and Merck Sharp &
Dohme; has received lecture fees from AZ, GSK, Boehringer/Pfizer, Alk-Abello,
and Meda; has received industry-sponsored grants from Trinity Cheisi, Meda
Pharmaceuticals, AZ, GSK, Altana, MSD, BI/Pfizer, and TEVA Pharmaceuticals;
and has received royalties from Elsevier Publications. P.M.O. has served on
advisory boards for AZ, GSK, Nycomed, Topigen, and Resistentia; has received
lecture fees from AZ, Chiesi, GSK, Nycomed, and Ono Pharma; and has received
industry-sponsored grants from AZ, Boehringer, Genentech, GSK, Medimmune,
Nycomed, Topigen, and Wyeth. M.R.P. has served on advisory boards for
Novartis, AZ, and Chiesi; and has received lecture fees from AZ, Novartis, Merck,
GSK, and Cipla. I.D.P. has received lecture fees from GSK, and AZ; has sat on
advisory boards for GSK, AZ, Merck, and Novartis; and has received industry-
sponsored grants from GSK. M.R.S. has received consultancies from AZ, GSK, and
Merck Frosst; has served on advisory boards for AZ, GSK, and Nycomed; has
received lecture fees from AZ, GSK, and Nycomed; has served as an expert
witness for AZ; has received industry-sponsored grants from AZ and Merck Frosst,
and holds an endowed chair jointly supported by AZ, and McMaster University.
P.J.S. has received lecture fees from GSK Netherlands and AZ; has received
industry-sponsored grants from GSK Netherlands and Topigen Canada; and
receives royalties from Elsevier Scientific Publishing. S.W.S. has received consul-
tancy payments from Alcon, Altana, AZ, Dey, Genentech, GSK, Merck, Novartis,
Sanofi-Aventis, Schering- Plough and Teva; serves on boards or advisory boards
for Altana, Alcon, AZ, Dey, Genentech, GSK, Novartis, Sanofi-Aventis, and
Schering-Plough; and has received lecture fees from AZ and GSK. S.D.S. has
received consultancy payments from Amgen, Genentech, Novartis and Schering-
Plough; has served on advisory boards for Merck, Schering-Plough, GSK,
Novartis; and has received industry-sponsored grants from Amgen, Genentech,
and Novartis. S.J.S. has served on advisory boards for AZ, GSK, Merck,
Genentech, Novartis, Verus, MAP, and Schering; has received lecture fees from
Merck; and has received industry-sponsored grants from Ross (Division of
Abbott). M.D.T. has served on advisory boards for GSK, MSD, Merck Pharma-
ceutical, Ivax, Altana, and BI; has received lecture fees from GSK, MSD, Merck
Pharmaceutical, Ivax, BI, and AZ; and has received industry-sponsored grants
89
from MSD, AZ, and GSK. S.E.W. has received consultancies from AZ, GSK, Merck,
Centocor, Genentech, and Novartis; has served on advisory boards for AZ, GSK,
Merck, Novartis, and Genentech; has received lecture fees from AZ, Merck, and
Critical Therapeutics; and has received industry-sponsored grants from Amgen.
Acknowledgment: The authors express their thanks to Professor Peter Sterk for his
inspiration and guidance in the initiation and completion of this project; to
Professor Ratko Djukanovic for his guidance in the establishment of the Task
Force; and to the staff of the American Thoracic Society and European Respiratory
Society for their assistance with Task Force meetings, symposia, teleconferences
and reports. Dr. Peter Wagner, Dr. Holger Schünemann, and Dr. Mark Wood-
head provided valuable advice during discussions about the Task Force publica-
tions.
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